East Dundee Dental Services


Main Street Dental is here for you. Every member of our team is 100% committed to helping you every-step-of-the-way. We are happy to answer your concerns, help you to understand every one of your treatment options, and help you in caring for your teeth and gums. We will work with you to develop a treatment plan that, when paired with regular exams and cleanings, will save you time and money. It will also keep your mouth healthy and smile looking its best.

New Patient Forms

Save time on your first appointment by filling out forms ahead of time

Before you have your first appointment you will have to fill out some forms.  To save time at the clinic, we have provided them here so you may fill them out ahead of time.  Please print and fill these forms out and bring them with you to your first appointment.

Patient Information Form

This form allows us to get to know you and learn about your current dental needs and physical health.

Notice of Privacy Practices

HIPPA Acknowledgement of Receipt of Notice Privacy Practice

Protecting your privacy is very important to us. This form acknowledges you have read and / or received a copy of Main Street Dental’s Privacy Practice document. These policies ensure we protect your personal information and are fully compliant with the requirements of HIPAA (Health Insurance Portability and Accountability Act).

Assignment of Benefits

This form gives Main Street Dental permission to work with your insurance company to directly receive health benefit payments.

Authorization to Disclose Health Information (optional)

Only sign this form if you want to authorize our office to discuss your treatment with another person, designated by you.

Schedule Your Appointment Today!

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