UNION DENTAL CARE

Jeffrey Hildebrandt DDS

17535 Rosbough Dr. #203

Middleburg Hts., OH 44130

440-243-8888 Fax 440-243-4575

Union Dental Care has permission to clean, examine, apply fluoride, and take whatever x-ray films deemed necessary for my child _______________________,

Parent/Guardian Signature _________________________________

Date ________________________

Default

2014-10-30

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