Revoke “Designation of Another Person to Consent for Dental Care”

Freeman Dental - Paducah

Please correct the errors described below.

to consent for dental care of my child.

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For Office Use Only

In order to process your Notice to Revoke, please bring this form with you to your next visit or fax it to Freeman Dental, PLLC at (270) 444-6033 for the Paducah Location. Thank you.

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