Previously Michet Dental
10729 163rd Pl, Orland Park, IL 60467
New Resident Registration Form
OR CALL (708)590-6380
Please choose an optionFirst AvailableMorningNoon-ishAfternoon
Please choose an optionI have a toothacheGeneral check-up/cleaningCosmetic consultationOther
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Patient’s Name *
Patient’s Phone Number *
Patient’s Email *
Would you like us to transfer your records from your previous/referring dentist?
NoYes
Referring Dentist’s Name *
Referring Dentist’s Office Name *
Referring Dentist’s Phone Number
Referring Dentist’s Email
I request and consent to the release of my dental records including but not limited to: x-rays, treatment history, diagnosis, or treatment plan.
