Call to schedule appointment (815-434-0737)
Open and print the forms below.
Send completed forms to:

Beth Mangold
Ottawa Friendship House
1718 N 2525 Rd
Ottawa, IL 61350           

 Forms (pdf files)

 MEDICAL HISTORY FORM

 CONSENT AND BILLING FORM

 PATIENT MANAGEMENT FORM

The next clinic at Friendship House will be on
March 28, 2012

 Ottawa Friendship will be hosting a dental clinic for adults with developmental   disabilities at our agency.  The clinic will take Medicaid, Insurance and Private Pay.
     Patients of the clinic must be at least 18 years old and have a documented disability. They do not have to be enrolled in an adult supportive service program to receive treatment.
     Dr. Jason Grinter will be the attending dentist. Dr. Grinter is a graduate of Dental Medicine from State University of New York at Buffalo School of Medicine. Dr. Grinter is the owner of Destiny Dental in Chicago, IL. Dr. Grinter is the attending dentist and director of special patient care with Advocate Illinois Masonic Mental Center. He has been the past Dental Director for Milestone Dental Clinic in Rockford which provides Medicaid dental treatment for individuals with developmental disabilities.
      If the patient is currently attending Milestone Dental Clinic in Rockford and would like to come to Ottawa Friendship House contact  Milestone to have records sent to the following address: Ottawa Friendship House 1718 North 2525 Road, Ottawa, IL 61350    
     If you are interested in sponsoring a clinic, or scheduling an appointment, please call Beth Mangold at 815 434- 0737 Ext.11.