Patient Forms


Downloadale & Printable Forms

Belmont Dental Care welcomes you into our family! If you are a new patient please see the below forms. These can be filled out ahead of time and either emailed or brought with you at the time of your first visit. Completing the forms in advance will save you time at your appointment. The first visit is a great opportunity to build the foundation of a long lasting dental relationship. Upon arrival of your first visit we will obtain your medical history, patient registration and give you time to get to know Drs. Parrott and Nguyen. Check out Our Doctors page to learn a bit more about your new Chicago dentists. They have been serving the Lakeview community for over 27 years. You’re in good hands!

New Patient Form

Please download and/or print the forms and bring them with you.

View Form

Pediatric Form

Please download and/or print the forms and bring them with you.

View Form

Contact Us

Belmont Dental Care
3344 N. Lincoln Ave.
Chicago, IL 60657
(773) 549-7971

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