Joshua H. Ehrlich, DMD PC

3118 N. Sheffield Ave. Ste. 1N, Chicago IL 60657
(773) 935-0300

REGISTRATION FORM

Please fill out this form and print it before your first appointment. Download PDF here.

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Insurance Information

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In Case of Emergency

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Joshua H. Ehrlich, DMD PC. I understand that I am financially responsible for any balance. I also authorize Dr. Ehrlich or my insurance company to release any information required to process my claims. Finally, I affirm that I have been offered and read the Office Privacy Policy according to HIPAA.

Patient/Guardian signature __________________________________________ Date  _____________________