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Get Last Changed 06062006 Last Reviewed 06062006 Owner Operations

CARE OF A MINOR I, , (Please Print Name) the undersigned parent or person having legal custody or the legal guardian of: , (Please Print Minor Child's Name) DO HEREBY AUTHORIZE , (Name of person to Whom Child is Entrusted) TO CONSENT TO any x-ray examination, anesthetic, medical, surgical, or dental d.

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