16 N Jackson Street, Belleville, IL 62220

New Patient Forms

Download Our New Patient Forms

When you first step into our modern dental office in downtown Belleville, you’ll see why we’re different – we value your time and want your appointment to be the best experience possible. If you are a new patient, we can help you be prepared for your first visit to our office by providing you with the following new patient forms.
Please print and fill out these forms before your first visit. Bring them with you and hand them to the receptionist when you arrive, and you’ll be that much closer to care from an established Belleville dentist with a reputation you can trust.

Notice of Privacy Practices
Dental Medical History
New Patient Form

You will need Adobe Acrobat to open these documents.

If you have any questions about these forms or your first appointment, please call our office at 618‑235‑5141 or use our online form to send us a message. We look forward to seeing you soon!