• Authorization to Release Information

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  • I, {yourName} give my permission to Natick Dental Partners and staff to discuss treatment provided and treatment recommended with the persons listed below until such time as I notify Natick Dental Partners and staff in writing that I am rescinding this authorization:

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  • Fluoride Treatment Form

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  • I, {name37} give my permission to have topical Fluoride treatments, I understand that these treatments may not be covered by my dental insurance.

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  • I, {name37} do not give my permission to have topical Fluoride treatments.

  • Clear
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  • Should be Empty: