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· I authorize the professional office of Volunteer Pediatric Dentistry and my dentist to release health information identifying me [including if applicable,

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Page 1: · I authorize the professional office of Volunteer Pediatric Dentistry and my dentist to release health information identifying me [including if applicable,

Page 2: · I authorize the professional office of Volunteer Pediatric Dentistry and my dentist to release health information identifying me [including if applicable,

Page 3: · I authorize the professional office of Volunteer Pediatric Dentistry and my dentist to release health information identifying me [including if applicable,

Page 4: · I authorize the professional office of Volunteer Pediatric Dentistry and my dentist to release health information identifying me [including if applicable,

Page 5: · I authorize the professional office of Volunteer Pediatric Dentistry and my dentist to release health information identifying me [including if applicable,

Page 6: · I authorize the professional office of Volunteer Pediatric Dentistry and my dentist to release health information identifying me [including if applicable,

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