Fox's Spokane Denture Clinic

Client Information

First name

Last name

Date of birth

Gender

Name of assisted living facility or nursing home:

Phone number

Email address

Address

Name of insurance policy holder

Member number

DOB of policy holder

Is there anything else regarding your medical history that we should be aware of?

Checkbox list

Full set of dentures

Full upper dentures

Full lower denture

Upper partial denture

Lower partial denture

Uni (single tooth partial)

Is there anything else regarding your dental treatment that we should be aware of?

By typing my full name below, I am signing that the above information is correct and true to the best of my knowledge.