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

X-Ray Release Form
Sleep Disorders

When visiting our office, make sure to bring your original:
Driver’s License or Valid ID
Dental Insurance Card
Vaccination Card
Negative PCR Test taken within 72 hours PRIOR to your appointment if not vaccinated

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

Dentist 60615

Stained Teeth | Preventative Dentist Hyde Park

September 15th 2022

Many people want a smile they can be proud of and one way to achieve a dazzling smile is to have pearly white teeth. However, in order to maintain a bright smile, the dentist says you should be mindful of...

Dentist in 60615

Don’t Rush to Brush | Hyde Park Dentist

September 1st 2022

Are you a diligent brusher who grabs the toothbrush as soon as you finish each snack or meal? While there are significant benefits to regular brushing, hurrying your hygiene might be doing more harm than good. The key lies in...

60615 dentist

Are You Using the Right Mouthwash? | Chicago IL Dentist

August 15th 2022

While it should never be used as a replacement for brushing and flossing, mouthwash can be a helpful addition to your at-home oral healthcare routine. Here’s what you need to know in order to pick the best mouthwash for your...


Hyde Park Dentist