Shine Pediatric Dentistry

New Patient Forms

Save time waiting in our office by filling out necessary forms online. Feel free to give us a call if you have any questions.

Patient Registration Form

Consent Form

Consent form to treat minors without parent/legal guardian present.

HIPAA Notice of Privacy Practices

Patient Financial Consent Form

Photo Release/Consent Form

Notice of Privacy Practices & HIPAA Consent

Have Questions? Get in Touch
If you have difficulty using our website, please email us or call us at (630) 743-6700
View the ADA Accessibility Statement