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EAST DUNDEE  |  (847) 783-0303

Forms for New Patients

In order to best serve you, there are some forms we need you to fill out. You can view the forms through the links below.

These forms can be filled out when you come to the office or you can print and fill them out in the comfort of your home; the choice is yours.

If you have any questions, please don’t hesitate to give us a call at (847) 783-0303 or send us an email at Info@MainStreetDentalOnline.com.

Patient Information Form

This form allows us to get to know you and learn about your current dental needs and physical health.

Main Street Dental Privacy Practice

HIPAA Acknowledgement of Receipt of Notice of Privacy Practice

Protecting your privacy is very important to us. This form acknowledges you have read and / or received a copy of Main Street Dental’s Privacy Practice document. These policies ensure we protect your personal information and are fully compliant with the requirements of HIPAA (Health Insurance Portability and Accountability Act).

Assignment of Benefits Form

This form gives Main Street Dental permission to work with your insurance company to directly receive health benefit payments.

Authorization to Disclose Health Information (Optional)

Only sign this form if you want to authorize our office to discuss your treatment with another person, designated by you.

If you’re unable to open PDF files, you can get Adobe Reader® for free.

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