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Format de fichier : Microsoft Word
AUTHORIZES: Drescher & Cohen DDS. 1201 Peachtree St. N.E. – Suite 1515 – Atlanta – Ga. 30361. TO DISCLOSE TO: Self Dental Provider Other ...
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Format de fichier : Microsoft Word
UNIQUE CHARACTERISTICS (Scars,Limp,Tattoo,Jewelry,Glasses,Etc.) DENTALRECORDS AVAILABLE? MEDICAL RECORDS AVAILABLE? FINGERPRINTS ...
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Format de fichier : Microsoft Word
A California licensed dental professional operating within his scope of practice ... If your child had a dental check-up in the 12 months before he/she started school, ask your dentist to fill out Section 2. ... Original to be kept in child's school record.
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Format de fichier : Microsoft Word
Disclosure of medical/dental information may contain all aspects of my treatment and ... Authorizations for release of mental health records expire in 180 days.
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Format de fichier : Microsoft Word
DENTAL HYGIENIST LICENSE RENEWAL – 2014 ..... Please indicate your acceptance of the Release and Certification by 1) checking the box “Yes” and 2) ...
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