New Patient Forms
Patient Registration - Fill Out Forms Online Now
You may preregister with our office by filling out our secure online Patient Registration Form. After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.
During your first visit, you will have a few forms to fill out. If you’d like to expedite your visit, simply fill out these forms by either printing them out and bringing them to your appointment or downloading the link below and filling it out on your computer. Once you have filled them out on your computer please save the file then upload it below.
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Thomas A. Bezouska, DDS, 3930 Washington Street, Gurnee, IL 60031