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Consent and Authorization (for medical, hospital and/or dental services)

The undersigned, on behalf of himself, or minor if applicable, hereby authorizes and consents to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care, to be rendered under the general or special supervision and upon advice of a physician and surgeon licensed in the State of Oregon, Washington, or California where applicable, and does also hereby authorize and consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care, to be rendered by a licensed dentist in the State of Oregon, Washington, or California where applicable. I hereby confirm consent, and agree to the foregoing.

GRANDPRIX

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