Patient Forms

(708) 873-9074

If you're a new client, please complete the following form and bring it to your first visit to our dentist office. This will ensure you to have the maximum amount of time with the doctor.

New Patient Form 
Agreement to Pay for Treatment Form 
Medical History Form 
Privacy Practices Acknowledgement

If you would like us to coordinate with another dental clinic to request x-rays, please complete this form:

X-Ray Release Form 
HIPAA Authorization Form


 This web site uses files in Adobe Acrobat Portable Document Format  (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.

Healthy Smiles

What does your smile say about you? Let us help you radiate confidence with a healthy smile.



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