Mercedes S - Las Colinas Endo
Las Colinas Endodontics Las Colinas Medical Plaza II
Specialists in Endodontics 7200 N. Hwy 161, Ste 215
Irving, TX 75039
Phone: 972.556.2100
Fax: 972.556.2112
Date: ______________________
I _________________________________ give Dr. Mercedes S. Dominguez permission to perform an exam and take diagnostic x-rays to determine treatment. I also give permission to discuss treatment, clinical notes and request x-rays from Dr. _____________________. If you have any questions please discuss with our office.
I give the following person(s) ____________________________ permission to discuss my medical or dental treatment with Dr. Dominguez and staff.
Patient/Parent Signature: _____________________________________
Sincerely,
Management
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