Contact Us: (708) 430-4440

Patient Resources

Patient Forms

For your convenience, you can fill out your registration forms prior to your appointment. Please click on the links below, print the forms and bring them to your next appointment with you. If you have any questions, please do not hesitate to contact us.

Patient Registration - Adult

Patient Registration - Child

Post Op Instructions

Payment Options/Financial Policies

Option 1 - Payment in Full at the Time of Service
Pay for the total cost of treatment with cash, check, Visa, MasterCard, American Express or Discover at time of service.

Option 2 - Payment over Three Months
Pay your cost or estimated out of pocket expense in 3 equal payments with the first payment due at first appointment.

Option 3 - Automatic Credit Card Withdrawl
Monthly payment plan on total cost of treatment or estimated out of pocket expense. Payment is automatically charged to your Visa, MasterCard, Discover, or American Express on a pre-arranged day of the month. One-third of the financed amount is due at the first appointment.

Care credit

Option 4 - Dental Fee Plan
Monthly payments on total cost of treatment with interest free options available through CareCredit Healthcare Financing. Click on the CareCredit logo to learn more.

Option 5 - Establish Credit Balance Before Starting Treatment

Option 6 - Discounted options on upfront payment for qualifying patients.