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718-441-2291
119-56 Metropolitan Ave.
Kew Gardens, NY 11415
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RELATIONSHIP TO PATIENT: SELFPARENTGUARDIANOTHER
Please list any dependent children under the age of 18 also covered by this acknowledgement #
I give permission for the following communications to be used by Metropolitan Smiles Family Dentistry PC: Cell phoneText Message reminders permittedHome phoneWorkEmail
I give permission for Metropolitan Smiles Family Dentistry PC to disclose their identity when calling; to anyone who may answer my phone: yesno
I grant permission for Metropolitan Smiles Family Dentistry PC to leave a message on: Home phoneWork PhoneCell PhoneWith any person who may answer when calling the home or cell phoneNone of above
I would like the following person(s) to have access to my personal information including but not limited to appointments, treatment, and billing of myself and any dependent children listed above #
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