Pediatric Dentistry of the North Shore

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Patient Forms

Online Patient Forms

For your convenience and in order to help ensure a successful visit, our office has made it easy for you to complete all forms online. Please be sure to complete them prior to your appointment to help avoid any delays. Below is a guide to understand which forms should be completed.  

When completing forms for multiple patients click on the “completed” green button to clear the form for the next patient. 

  • Medical History– must be completed for new patients and updated every 2 YEARS for current patients (think of the last two years when answering the questions)

  • Insurance Information– to be completed for new patients OR current patients with recent changes/updates to their dental insurance

  • HIPAA/Financial – must be completed for new patients or by current patients at age 18

  • Contact Information– to be completed for new patients or current patients with changes to their address, phone numbers, and/or email address

School Forms

Children entering Kindergarten, 2nd grade, 6th grade, and 9th grade are required by the state of Illinois to have proof of a dental examination on file with their school.  Please complete the top section of the form and email to office@pediatricdentistns.com. We will then email or mail back to you.