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ORAL SURGERY CONSENT FORM 876 Columbia Street Hudson, NY 12534 www.columbiastreetdentalgroup.com (518) 6716002Date: I, agree to have toothed/teeth # extracted. I fully understand the POSSIBLE COMPLICATIONS

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876 Columbia Street is often referred to as a specific address, but without specific context, it may refer to a residential or commercial property located at that location.

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Individuals or businesses that have transactions or activities associated with the property at 876 Columbia Street may be required to file relevant documentation if required by local regulations.

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