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Wavier Form

Please fill out the following form.

Date of birth
Month
Day
Year
In consideration for the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and into this waiver and release of liability and hereby waive any claims.
No
Yes
You understand staff of Hubbard Smiles are NOT medical professionals such as licensed dentist, oral surgeons, nurse practitioners, physician assistants, medical doctors (non-surgical) including specialists like dermatologists.
No
Yes

Thanks for submitting!

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