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-2pm
Saturday: 8am-1pm

Contact
Our Office

(773) 643-6006 Request Appointment
Patient Name:

Read Our Hyde Park Dental News

Chicago Dentists

Chicago IL Dentist | Dental Care Tips While Traveling

May 23rd 2020

When you are traveling, it can be challenging to keep up with your usual daily routine. For many people, this can include having difficulty finding the time to properly brush and floss. Whether you are traveling for business or pleasure,...

Chicago IL Dentist | One Tool for Better Gum Health

May 14th 2020

Loose teeth, bad breath, and painful, bloody gums - these are among the signs and symptoms of periodontal, or gum, disease. Unfortunately, periodontal disease can also begin without any obvious symptoms. If left undiagnosed or untreated, you could be at...