Patient Forms

We invite you to prepare for your visit with Dr. Cusack by printing and filling out our patient forms. Bring them with you to your appointment at our dental office to save some time and to streamline your experience. You can also fill out and submit the forms online! Please call or visit Blaine P. Cusack, DDS General & Holistic Biological Dentistry if you have any questions. Our friendly and knowledgeable team members are always here to take your calls at 708-482-0300 to answer your questions and schedule your consultation with our experienced dentist in Countryside, Illinois!

New Patient Forms

Head, Neck, Face Questionnaire

Orthodontic Questionnaire

Sleep History Questionnaire

Oral Appliance Therapy Consent Form

TMJ Screening Consultation Questionnaire