Patient Forms

To make your appointment go smoothly and without delays, please view and fill out our patient forms prior to visiting our dental office in Chicago, Illinois. If you need assistance, please don’t hesitate to contact us. We are excited about your visit to our office.

General Forms

MEDICAL HISTORY FORM

NEW PATIENT FORM

New Patient Form (Español)

Office Policy & Payment Policy

Deposit Policy

First Commonwealth Oral Surgery Policy

Pre Authorization Policy

HIPAA Form

Consent Forms

Orthodontic Consent Form

Oral Surgery Consent Form - Dr. Bruno

Dental Implant Consent Form - Dr. Bruno

Extraction & Grafting Consent Form - Dr. Bruno

Oral Surgery Consent Form - Dr. Abughazaleh

Periodontal Surgery Consent Form - Dr. Yousuf

Dental Implant Consent Form - Dr Yousuf & Dr. Abu

Endodontic Treatment Consent Form - Dr. Khan

Endodontic Treatment Consent Form - Dr. Moussa

Endodontic Treatment Consent Form - All other Drs

Zoom Teeth Whitening Consent

Post Op Instructions

Oral Surgery Post Op Instructions

Oral Surgery Post Op Instructions - Dr. Bruno

Endodontic Post Op Instructions - Dr. Khan

Endodontic Post Op Instructions - Dr. Moussa

Periodontal Surgery Post Op Instructions

Periodontal Surgery Post Op Instruction - Spanish

Zoom Whitening Post Op Instructions

Very helpful staff & nice office

My dentist was really nice, straightforward, and made sure to check in with me many times throughout my cleaning to make sure everything was alright. Didn't seem pushy or judgmental (even though it was my first cleaning in years). Very helpful staff and nice office, too.

Ashley Donegan Chicago, IL