420 N Evergreen Rd # 400, Spokane Valley, WA 99216

I have read and been offered a copy of the privacy practices for Chet A. Hymas, DMD PLLC.
Date:
Relationship to patient: Self Parent Guardian Legal Representative
 
I give my consent to allow the following person(s) access to my dental/medical information:
 
Name
Relationship
Initials
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