386 Pennsylvania Ave., Ste 1 North, Glen Ellyn, IL 60137

630.858.2198

Loree S. Nicholas, DDS, PC
 General, Cosmetic, & Family Dentistry

 

 

Welcome to Our Practice

New Patients Forms

New patients... please print, complete and sign forms 1-7. It is not necessary to print the Privacy Practices form #8. By signing and completing form #7, that assures us that you have read and understand our privacy procedures #8. Please bring the completed forms along with your current dental insurance card to your appointment. We thank you and look forward to meeting you very soon.

  1. Patient Registration
  2. Medical History
  3. Office and Financial Policy
  4. Easy Pay Authorization
  5. Communication Authorization
  6. Treating a Minor
  7. Privacy Form
  8. Privacy Practices

 

Appointment/Information Request Form

 

 Name

 E-mail

Telephone

Address

City, State, Zip

For appointment Requests

Reason for the appointment

Days and hours you prefer

  

For additional information request

Please send me information about 

  

 

 

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