Dental Patient Registration Forms

Office Forms

You may register with our office by filling out our printable online forms. After you have completed the forms in their entirety, please make sure to bring them with you at the time of your appointment.

Please call our office if you have any questions:

Forsyth IL Periodontal Office Phone Number 217-876-0547 (Forsyth) or Springfield IL Periodontal Office Phone Number 217-787-0422 (Springfield).

Pre-Appointment Screening

In light of the Coronavirus outbreak, all patients will need to complete this questionnaire to help assure your safety and the safety of those around you before being seen at the office. Thank you in advance for completing it.

If you answer YES to any of these questions, please call the Forsyth office: Forsyth IL Periodontal Office Phone Number 217-876-0547. If all your answers are NO, we will see you at your regularly scheduled appointment time, where these questions may be asked again and your temperature taken with a no touch thermometer. Again, thank you for your cooperation.

Pre-Appointment Screening Questions

Technical Note

These forms are in PDF format. If you do not have Adobe Reader installed on your computer, you may download Acrobat Reader for free and use it to access these forms.

Request An Appointment

Contact Magnolia Pedraza, DMD, MS

The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment. Note: If you are an existing patient, this contact form should not be used to communicate private health information.
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