Dental Patient Registration 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.
- Medical History Form
- Office Policy: For Insured Patients
- Office Policy: For Non-Insured Patients
- Acknowledgement of Receipt of Privacy Practice and Disclosure
- Notice of Privacy Practices and Healthcare Information Disclosure
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).
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.
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.