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Get Canada Standard Dental Claim Form 2003-2024

DENTURE, CROWN OR BRIDGE, IS THIS INITIAL PLACEMENT? GIVE DATE OF PRIOR PLACEMENT AND REASON FOR REPLACEMENT. ❏ NO ❏ YES IF STUDENT, INDICATE SCHOOL ________________________________________________________ 5. IS ANY TREATMENT REQUIRED FOR ORTHODONTIC PURPOSES? ❏ NO ❏ YES PATIENT I.D. NO. ____________________________________________________________________ 6. I AUTHORIZE THE RELEASE OF ANY INFORMATION OR RECORDS REQUESTED IN RESPECT OF THIS CLAIM TO THE INSURER / PLAN ADMINISTRAT.

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