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Growing beautiful smiles




Please download the attached PDFs and either bring them with you to your first appointment or fax them to (847) 673-5002 ahead of time for easy check-in.

Download PDF Forms

New Patient  forms for Dental Associates of Old Orchard

New Patient Form
Insurance Form
Financial Form

Request An Appointment Now!

After receiving your form a representative from Old Orchard Smiles will be in contact with you within 24 hours to schedule an appointment time.

 

First Name
Last Name
Phone
Email
 
Are you a New Patient? Yes No
How Did You Find Us?
Name Referral Source Above:
 
Preferred Method of Contact? PhoneEmail
Do you have Dental Insurance? YesNo
If yes, Dental Insurance Company:
About Your Appointment:
1st Preferred Day
2nd Preferred Day
Preferred Time
Type of Appointment
Additional Info*
* Please do not submit any protected health information (PHI).
Business Hours
Hours of Business
  • Mon 11-7
  • Tues 10-7
  • Wed Closed
  • Thr 9-6
  • Fri 9-2
  • Sat 9-2 (alt)