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  • How did you leam of Modem Family Dental Care?
    Direct Mailing Friend/Relative Internet Search Insurance Plan Newspaper Ad Exterior Sign Facebook Twitter Other __________ Tf you were referred, whom may we thank for referring you? ___________ _
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    Twill answer all health questions on the Medical History From to the best of my knowledge. ____ (Initials)
    After explanation by the doctor, l hereby authorize the performance of dental services upon the above named patients and whatever procedures that the judgment of the doctor may decide in order to carry out these procedures. r also authorize and request the administration of any anesthetics and x-rays as may be deemed necessary and advisable by the doctor.
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