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  • MEDICAL HISTORY

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  • Has your child had a history of :

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  • DENTAL HISTORY

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  • FAMILY INFORMATION

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  • AUTHORIZATION AND FINANCIAL RESPONSIBILITY

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  • To the best of my knowledge, all of the preceding answers are true and correct. If there is ever any change in my child’s health or if my child’s medicines change, I will inform the doctor of dentistry at the next appointment without fail.

    I acknowledge by signing this form, I will be financially responsible for my child’s account.

    I hereby authorize DR. MAHNAZ GORGANI, DR. NATALIE VANDER KAM and/or their associates to perform any and all treatment for my above named child and consent to such methods, drugs, and agents as may be indicated in connection with his/her dental care. This consent shall remain in effect until cancelled

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