Accessible Version
LJ Dentistry
A Great Dentist
Moline, East Moline, Rock Island and all surrounding Quad City areas.
Office Hours: M-Th:8-5 F:8-2

New Patient Forms

Help us get to know you!

Please take a moment and fill out our patient information form. If you have any questions along the way, feel free to contact our practice.

Health History

Please follow the link and choose EXISTING PATIENT. You will then choose between The New Patient(14+), New Patient (Child), or Existing Patient Update packets according to your status as a patient in our office. If you are a Sleep Apnea patient, please choose the Sleep Patient packet.

The system will have you verify that it is you by having you fill out the basic information that we already have in our system.

If you are checking for a HIPAA policy, that will be available in above the packet selections.

We would love to help you if you have any questions or concerns.

Have Questions? Get in Touch
If you have difficulty using our website, please email us or call us at (309) 764-3242
View the ADA Accessibility Statement