PerioCare
Periodontics & Dental Implant Surgery
Russell J. Cecala, DDS, MS
Call: (773) 631-0344

Patient Forms

If you are a new patient to our office, the attached file contains our new patient bundle with forms that will need to be filled out when you arrive at our office.  Printing them, filling them out and bringing them with you will allow us to attend to your medical needs more quickly than completing them on your arrival.  Thank you and please call our office if you have any questions at all.

New Patient Forms


Health History Form

Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

Consent For Use and Disclosure of Health Information

Office Policy

Patient COVID 19 Consent Form

 

Other Patient Forms


Postoperative Instructions Following Periodontal Surgery

Postoperative Instructions Following Tooth Extractions

Postoperative Instructions Following Sinus Grafting

Postoperative Instructions Following Laser or Gingival Graft Surgery

Instructions Prior to IV Sedation