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 · AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION The Loose Tooth Pediatric Dentistry 15041 S. Van Dyke Rd, #105 Plainfield, IL 60544

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Page 1:  · AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION The Loose Tooth Pediatric Dentistry 15041 S. Van Dyke Rd, #105 Plainfield, IL 60544
Page 2:  · AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION The Loose Tooth Pediatric Dentistry 15041 S. Van Dyke Rd, #105 Plainfield, IL 60544
Page 3:  · AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION The Loose Tooth Pediatric Dentistry 15041 S. Van Dyke Rd, #105 Plainfield, IL 60544
Page 4:  · AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION The Loose Tooth Pediatric Dentistry 15041 S. Van Dyke Rd, #105 Plainfield, IL 60544
Page 5:  · AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION The Loose Tooth Pediatric Dentistry 15041 S. Van Dyke Rd, #105 Plainfield, IL 60544
Page 6:  · AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION The Loose Tooth Pediatric Dentistry 15041 S. Van Dyke Rd, #105 Plainfield, IL 60544
Page 7:  · AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION The Loose Tooth Pediatric Dentistry 15041 S. Van Dyke Rd, #105 Plainfield, IL 60544

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