Patient Forms - Flee Mclemore dds

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(817) 594-8665
leemclemoredds@sbcglobal.net

610 Eureka St. Weatherford, TX 76086

F. Lee McLemore, DDS

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Patient Information (CONFIDENTIAL)

Social Security

Date

Name

Birthdate

Cell Phone

Address

City

State

Zip

Check Appropriate Box

Minor Single Married Divorced Widowed Separated

If Student, Name of School / College

City

State

Please Select Any One

Full Time Part Time

Employer (or Parent’s Employer)

Work Phone

Business Address

City

State

Zip

Spouse

Employer

Work Phone

Whom May We Thank for Referring You?

Person to Contact in Case of Emergency

Phone

Step 1

Responsible Party

Name of Person Responsible for this Account

Address

Home Phone

Driver’s License

Birthdate

Social Security

Employer

Work Phone

Relationship to Patient

Is this Person Currently a Patient in our Office?

Yes No

Payment in full at each appointment. For your convenience, we offer the following methods of payment. Please check the option you prefer.

Cash Personal Check Visa Mastercard Discover American Express

Step 2

Insurance Information

Name of Insured

Relationship to Patient

Birthdate

Social Security

Date Employed

Name of Employer

Union or Local

Work Phone

Address of Employer

City

State

Zip

Insurance Company

Group

Policy/ID

Ins. Co. Address

City

State

Zip

How Much is Your Deductible?

How Much Have You Used?

Max. Annual Benefit

Max. Annual Benefit

Services Areas

Weatherford, TX
Stephenville, TX
Hudson Oaks, TX
Aledo, TX
Brock, TX
Mineral Wells, TX
Cresson, TX
Granbury, TX
Cleburne, TX
Glen Rose, TX

About Us

At F. Lee McLemore, DDS, we’re not just your dental care providers; we’re your partners in achieving and maintaining a healthy, beautiful smile.

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Services

Cosmetic Dentistry
General Dentistry
Geriatric Dentistry
Pediatric Dentistry
Special Needs Dentistry

Map

Contact Us

817-594-8665

leemclemoredds@sbcglobal.net

610 Eureka St. Weatherford, TX 76086

Monday -Thursday:
8:00 am to 5:00 pm

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