David Hertzberg, DDS, MS
160 Commerce Drive,
Suite 101
Grayslake, IL 60030
Tel: 847-548-4330

Patient Forms

Patient Forms

Please take a minute to print and fill out the patient information form before your first appointment:

 

┬╗ GO HIPAA Consent [PDF]
┬╗ GO Notice of Privacy Practices [PDF]
┬╗ Ortho Health History Spanish [PDF]
┬╗ Ortho Health History [PDF]
┬╗ Ortho Registration Spanish [PDF]
┬╗ Ortho Registration [PDF]

 

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