Bruce H. McClaire D.D.S.
General, Reconstructive, & Cosmetic Dentistry

Status

Name

By what name should our staff address you?

Birth Date

Name of Spouse


Home Address

Home Phone

Patient Employed by

Business Address

Present Position

Spouse Employed by

Business Address

Present Position

I UNDERSTAND THAT INSURANCE COMPANIES
DO NOT PROVIDE 100% COVERAGE OF DENTAL FEES.

I understand that I am financially responsible for all work
provided regardless of any insurance coverage. I am
responsible for updating records, address changes,
phone number, employee and insurance information.

 

In Case of Emergency, we will notify

Please include Name and Phone Number

Who will pay this Account?


Do you have Insurance? Yes No
Insurance Company Name

Group#
Policy#

Whom may we thank for referring you?


Reason for Appointment


Date of last Dental Appointment


Are you in good health?

Date of last medical appointment

For what purpose

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