5 W. Second Street, Suite 7 Hinsdale, IL 60521
T. 630.325.7700 info@surjandental.com
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Please print, complete and present this form to reception on your first appointment.
Patient Forms
You can print this or obtain a paper copy from us at the office. This form is for your records.
Notice of Privacy Practices
This form is required for all children in Kindergarten, Grade 2, and Grade 6 in Illinois. Fill out the top section and bring it with to your child's exam.
Illinois Proof of Dental Exam