360 San Miguel Dr #508Newport Beach, CA 92660
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As Parent(s) of ,I authorize Dr. Daghlian, Dr. Sokolowski and associates to examine and treat my child as necessary. By signing this form I am accepting responsibility for full payment of services rendered, including services that may not be fully covered by my insurance plan.
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Tel: 949-706-7006 360 San Miguel Dr #508, Newport Beach, CA 92660
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