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Main Street Square Dental

Main Street Square Dental

Downers Grove, Illinois Dentists

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Patient Forms

Dentist Downers Grove, IL

For your convenience, you may download and print our forms prior to your office visit. All of the forms are in PDF format. Most modern browsers can display and print PDF documents and you can always download free software from Adobe to do so.

New Patient Forms

This PDF includes the following documents:

  • Welcome Document (2 pgs)
  • Written Financial Policy (1 pg)
  • Insurance Release and Assignment of Benefits (1 pg)
  • Privacy Release and Disclosure Statement (1 pg)
  • Notice of Privacy Practices (3 pgs)

Download New Patient Forms

X-Ray Release Form

This PDF includes the following documents:

  • X-Ray Release Form
Download X-Ray Release Form


Existing Patient Update Forms

This PDF includes the following documents:

  • Welcome Document (2 pgs)
  • Insurance Release and Assignment of Benefits (1 pg)
Download Existing Patient Update Forms
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Contact Us Today

At Main Street Square Dental in Downers Grove, IL, we provide our patients with access to state-of-the-art facilities along with the most experienced and dedicated healthcare professionals. In 2019, Dr. Samee and Dr. Peterson re-opened the doors to patients in the city of Downers Grove. Since then, our mission has been to provide quality care in a safe environment — earning us a reputation as the best Dental Clinic in the area.

Contact Us Now!

Connect With Us

Contact Us

Main Street Square Dental
2932 Finley Road
Downers Grove, IL 60515

(630) 629-6299

Hours

Monday: 9am – 6pm
Tuesday: 7am – 2pm
Wednesday: 9am – 6pm
​Thursday: 7am – 2pm
​Friday: Closed
​Saturday: By Appt.
​Sunday: Closed

Association and Memberships

SMART Certified Dentist- Safe Mercury Amalgam Removal Technique
International Academy of Oral Medicine and Toxicology

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