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
We have received guidance from the Illinois Department of Public Health and can now resume routine dental care.  We have spent the time off researching all the new guidelines so that we can so that we can safely reopen. To read our reopening guidelines in full, CLICK HERE.