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


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






City, State, Zip

For appointment Requests

Reason for the appointment

Days and hours you prefer


For additional information request

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