accessibility ACCESSIBILITY
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

Other Patient Forms

Medicare Contract

Postoperative Instructions Following Periodontal Surgery

Postoperative Instructions Following Tooth Extractions

This web site uses files in Adobe Acrobat Portable Document Format  (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.