Referral Form - Houston, TX

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The image shows a dental office setting with a patient sitting in a dental chair. Two dental professionals, a male and a female, are standing beside the patient. They are both smiling and engaged in conversation with the patient, creating a welcoming and friendly atmosphere. The male dental professional is holding a dental tool, and there are various dental instruments visible in the room. The background features a poster of a smiling person and a display screen, indicating a modern and well-equipped dental clinic. This image highlights the professionalism and patient-centered care provided in the dental practice

Referral Form

I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act.

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