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Treatment Refusal Form

Treatment Refusal( * mandatory to fill )

Treatment I am refusing today *
Topical Fluoride
X-rays
Parent, Guardian Signature *
 
(Please click below to draw/upload sign)
(Your IP Address : )
Treatment Refusal Form
First Name:           Last Name:           Date Of Birth:          
Treatment I am refusing today Topical Fluoride X-rays
         
 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
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