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Dental Forms
Prior to your appointment, please click on the appropriate forms below, download, and print. Completely fill out the forms prior to your office visit and bring them with you.
Notice of Privacy Practices (PDF)
Acknowledgement of Receipt of Notice of Privacy Practices (PDF)
Consent for Use and Disclosure of Health Information (PDF)
Patient Information - About You (PDF)
Medical History (PDF)
Minor Patient's Parent Information (PDF)
X-Ray Request Form (PDF)
Records Release Request (PDF)
© 2009 Plum Grove Dental Associates, Ltd. | 222 N. Plum Grove Rd. | Palatine, IL 60067-5233 | 847-359-4700
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