P. Bruce Easter, DDS, P.C.  

317.291.1000
Family, Cosmetic and Sports Dentistry  
 

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Appointment Request

Begin Scheduling Your Appointment Online

We can begin scheduling your appointment immediately if you provide us with the following information.
We'll contact you via your preferred method with your appointment date and time.

* indicates required field.

Why Are We Asking You For This Information?

We need your insurance ID number or Social Security number to confirm your eligibility. Such information will be used solely by Dr. Easter, DDS, P.C. or its representatives for the purpose of confirming eligibility, evaluating and administering claims for benefits and as otherwise permitted by HIPAA policy or under law.

 

Patient Information

First name *   Middle initial
Last name * Suffix (Jr., etc.)
Birth date *
 /   / 
Gender *
 Male    Female
Parent Name
(if Minor)		    
Home Phone # *
 –   – 
   
Cell Phone #
 –   – 
   
E-mail address    
Please contact via    
Best time to contact    

Appointment Details

Has the patient been to Dr. Easter before? *    
 Yes    No
Preferred day of week *
Preferred appointment time *
Reason for this visit *
Is the patient covered by dental insurance? *    
 Yes    No
Comments   
How did you hear about us?

Guarantor (person financially responsible)

Person financially responsible for payment *
First name * Middle initial
Last name * Suffix (Jr., etc.)
Birth date *
 /   / 
 
Address *
City *
State * Zip Code *

Primary Insurance Information

Insured's name:  
Insurance company name  
Insurance company phone  
 –   – 
   
Employer name  
Employer group number  
Unique Member ID#   (Your unique insurance ID number can be found on your insurance card.)

 

 

 

 

 

 

 

 

3935 Eagle Creek Parkway, Suite A
Indianapolis, IN 46254

317.291.1000
Fax 317.291.3400
info@easterdds.com