Fox's Spokane Denture Clinic

First name

Last name

Date of birth

Gender

Does patient reside in assisted living facility or nursing home?

Yes

No

Name of assisted living facility or nursing home:

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Please upload a file

Phone number

Email address

Address

Insurance Information

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)

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Date