Benjamin C. Youel DDS, MS
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]


If you're unable to open PDF files, you can get Adobe Reader® for free.