Dentist | Vancouver | Lee Family Dental

Patient's Name

Phone Number

Email Address

Date of Birth

Reason for Appointment

Do you have dental insurance? Yes or No

If you have a dental insurance, please write Insurance name, Subscriber ID# or Social secrity#, Group # and Insurance phone #. Please write N/A if not applicable.

If you are not the insurance subsriber, please write a subscriber's name and date of birth. Please write N/A if not applicable.