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t, I <br /> _IPt Dr. Rummelhart <br /> FROM DOESIGN TO , <br /> (608)273-3258 Fax(608)288-5579 <br /> Deliver to: 1402 Greenway Cross <br /> DENTAL ❑ OLD SAUK ❑ EAST Madison,WI 53713 <br /> HEALTH 7017 Old Sauk Road 49 North Walbridge Avenue <br /> ASSOCIATES Madison,WI 53717 Madison, WI 53714 <br /> OF MADISON LTD. <br /> Fax orders to Econoprint at (608) 288-5579 <br /> Ordered Quantity <br /> Item Form# Description of Item Needed <br /> am RU-2A Periodontal Cards (one-sided) <br /> faRU-2B Periodontal Cards (two-sided) <br /> INC <br /> RU-3 Informed Consent for Periodical Surgery <br /> RU-4B Periodontal Evaluation Reminder (Old Sauk) <br /> RU-5 Health Questionnaire/Update Card <br /> E RU-6 Periodontal Insurance Information <br /> RU-7 Periodontics Department Postoperative Instructions <br /> ERU-11 Perio Exam Sheets <br /> RU-12 Service/Charge Form <br /> RU-13 Medical History Form <br /> CCRU-14 Line Sheets <br /> • <br /> LE <br /> RU-15A Postcard of Records (Old Sauk) <br /> RU-15B Postcard of Records (East) <br /> CIRU-16 Maintenance Therapy <br /> RU-17 PT Form <br /> ❑ REORDER FORMS FROM ECONOPRINT <br /> Additional Instructions: <br />