Patient Forms

Chicago Family Dentists

To provide you with the most efficient new patient experience, please click the links below to complete and submit your forms electronically. If you have any problems submitting your forms, please contact our office.


New Patient Information
Health History
Notice of Privacy Practices HIPAA
Financial Policy
Patients Out of Network
Patient Photo Consent
ADA Patient Screening Form

When visiting our office, make sure to bring your original:
Driver’s License or Valid ID
Dental Insurance Card

Upload Your Cards Here

Visit Our
Chicago Office

Located in the historic
Hyde Park Bank Building

Hyde Park Family Dentist
1525 E. 53rd. St. Suite 734
Chicago, IL 60615

(773) 643–6006 |

Convenient
Office Hours

Monday: 8am-4pm
Tuesday: 8am-5pm
Wednesday: 8am-4pm
Thursday: 8am-5pm
Friday: 8am-3pm
Saturday: 8am-1pm

Contact
Our Office

(773) 643-6006 Request Appointment
Patient Name:

Read Our Hyde Park Dental News

Chicago Dentists

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Don’t Miss Your Screening | Cosmetic Dentist in Hyde Park

December 1st 2021

Oral cancer does not discriminate. It affects those of all ages, genders and races. Smokers do develop oral cancers at higher rates than non-smokers. However, this does not absolve the rest of the population from being at risk, as well....

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Preventing Enamel Erosion | Restorative Dentist in Hyde Park

November 15th 2021

Do you have white spots on your teeth? Are your teeth quite sensitive? Do your teeth have cracks, chips, or indentations? If yes, then you may be experiencing enamel erosion. Tooth enamel is the hardest substance in the human body....

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Oral Hygiene at Work | 60615 Dentist

November 1st 2021

Do you brush your teeth after lunch? If you're one of the millions of people who work outside the home, chances are you don't have the time or resources to brush during the day. However, not being able to brush...