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5307 N. Harlem Avenue Chicago, IL  60656        773-774-4331            rgrubekdds@yahoo.com

Book Now! New Patient Information Reviews


Please assist us by providing the following information at the time of your first visit to our office:

Your X-rays if applicable.

A list of medications you are presently taking.

If you have dental insurance, bring your insurance card. This will save time and allow us to help you process any claims.

 

Please alert the office if you have a medical condition that may be of concern prior to treatment (i.e. diabetes, high blood pressure, artificial heart valves and joints, rheumatic fever, etc.) or if you are on any medication (i.e. heart medications, aspirin, anticoagulant therapy, etc.) or require medication prior to dental cleanings (i.e antibiotics, for pre-med.)


 

If your previous dentist has taken recent x-rays (within 6-months), you may request that they forward them to our office. If there is not enough time, please pick them up and bring them to our office. If additional films are necessary, they can be taken at our facility.

Registration Form Notice of Privacy Practices Health History Page 1 Acknowledgement of Privacy Practices Health History Page 2 Financial Policy

Please print, fill out, and bring to your first appointment.