div class=trans-pagebuttonPage 1button div class=trans-image amp-img class=trans-thumb alt=Page 1: · 2016 6 13 · I am financially responsible for any balances due and authorize the dentists to release any information for this claim I authorize that my records can be used src=https:reader036fdocumentsinreader036viewer20220710115fc9484c0aaae551156235b8html5thumbnails1jpg width=142 height=106 layout=responsive amp-img divdiv