Beautiful Smiles of La Grange Nancy D. Cozzi, D.D.S
Beautiful Smiles of La GrangeNancy D. Cozzi, D.D.S

Patient Forms

New patient? Please download and fill out the following forms when you come in for your first appointment:

  • HIPPA Signature Form
  • New Patient Information Form (Child/Adult)
  • Written Financial Policy

For your first office visit, we ask that you would also bring:

  • Insurance card
  • Valid photo ID

 

Also, check out our interesting dental facts for more information about the health and history of your teeth.

HIPPA Information and Signature Sheets

Please read over the HIPPA Information Sheet and sign our HIPPA Signature Form, acknowledging our privacy policy. The Signature Form should also be brought to your first appointment.

HIPPA Information Sheet 2013
2013 HIPPA Form.docx
Microsoft Word document [16.7 KB]
HIPPA Signature Form
HIPPA NOTICE OF PRIVACY PRACTICE.doc
Microsoft Word document [22.0 KB]

New Patient Information Form

This form is mandatory for new patients. To expedite your visit, print this form, fill it out and bring it with you for your first visit. Please note that we have two separate forms depending on if the patient is a child (16 and under) or adult.

New Patient Information Form - Child (side 1)
New Patient - Child 1.pdf
Adobe Acrobat document [582.8 KB]
New Patient Information Form - Child (side 2)
New Patient - Child 2.pdf
Adobe Acrobat document [492.4 KB]
New Patient Information Form - Adult (side 1)
New Patient - Adult 1.pdf
Adobe Acrobat document [777.8 KB]
New Patient Information Form - Adult (side 2)
New Patient - Adult 2.pdf
Adobe Acrobat document [765.7 KB]

Written Financial Policy

This form details the financial policies of our office. Please fill this form out and bring it in for your first appointment.

Written Financial Policy
Please fill this form out and bring it in for your first appointment.
Written Financial Policy.docx
Microsoft Word document [14.5 KB]

Call us at: (708) 579-1522

 

Beautiful Smiles

1400 W 47th St

La Grange, IL 60525

Email: ndcozzidds@msn.com

 

Use our contact form to get in touch.

Keep Your Teeth Healthy!

What is the best preventive care for your teeth? Find out how to make your next visit easier and more pleasant.

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