412 Crystal Street, Cary, IL 60013
Thomas J. Skleba, DDS, FAGD
Sarah S. Brewer, DMD
Please complete and submit this form prior to your first visit. We look forward to working with you in maintaining your dental health.
Download / Printable PDF available below
Patient Form PDF Download
Analyze your smile
Patient History Form
(Please bring a copy of your Dental Insurance Card. This may be different than your medical carrier. Please verify.)
Primary Policy Holder:
(Please have x-rays forwarded to info@carydentalassociates.com prior to your first visit or new sets will be taken)
Although dental personnel primarily treat the area in your mouth, your mouth is a part of your entire body. Please list any health problems you may have or any medications that you are taking.
Are you allergic to any of the following?
Have you ever had any serious illness not listed YesNo