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Hammer and Van Want Dental Brian C Hammer, DMD and Assoc, PSC 2405 Ring Road, Elizabethtown, KY 42701, (270)7378828Patient Information Patient Name: (First) ___ (Last)___ (MI) ___ Date: ___ Birth

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Hammer and Van Zant is a financial disclosure form used to report certain financial transactions.

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Information such as sources of income, investments, loans, and other financial transactions must be reported on Hammer and Van Zant.

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