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Does the patient have or has he/she ever had:
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I authorize payment directly to Horner Barrow Orthodontics, PC.
By signing below, I certify that the information I have provided today is complete and accurate. I also understand that it is my responsibility to inform the office of any changes regarding my (or my child's) medical health. I authorize ithe dental staff to perform necessary dental services that I, or my child, may need during diagnosis and treatment.
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