For your convenience, click on the buttons below to download or print forms needed for your first appointment. If you are unable to print, please email us at      rima@countrywidesmiles.com or use the "Contact Us" tab, and we will email back all the needed forms:



1. Enrollment Application of In-Office Discount Dental Plan

2. Medical History form

3. HIPAA Privacy Form

4. Care Credit Application form

5. Financial Policy

                                                                                                                                              309-935-6126


For your convenience, you could fill these out and bring them to your appointment