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Download - howardglazerdds.com name Patient number Patient address Patient phone number I authorize the professional office of my dentist named above to release health information identifying

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Page 1: howardglazerdds.com name Patient number Patient address Patient phone number I authorize the professional office of my dentist named above to release health information identifying
Page 2: howardglazerdds.com name Patient number Patient address Patient phone number I authorize the professional office of my dentist named above to release health information identifying
Page 3: howardglazerdds.com name Patient number Patient address Patient phone number I authorize the professional office of my dentist named above to release health information identifying
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