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Signature Endodontics Samuel H. IP D.D.S 30212 Tomas, Suite 210 Rancho Santa Margarita, CA 92688 949) 5894819 949) 5894841 (fax)INFORMED CONSENT I ___ have been advised by my referring dentist that

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I have been advised by a legal counsel.

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To fill out ihave been advised by, one must provide details of the legal advice received.

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