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  • Bad Dental Experience Patient Communication E-Form

    Our goal is to provide you with the best possible experience. Please outline any of your concerns you may have regarding visiting the dentist.” All written text box descriptions are optional and provided only for those who would like to share more detail.
  • Dentistry Phobia’s & Fears

    Please do not assume we are looking for a specific standardized answer. Please do your best to truthfully and honestly answer the following questions. In doing so, you will give us the greatest chance to provide you with the best possible experience.
  • Rank Your Fears and Anxiety related to the following List:

    1. Strongly Agree

    2. Somewhat agree

    3. Neither agree or disagree

    4. Somewhat disagree

    5. Strongly disagree

  • Past Problems with the Dentist & Clinical Treatments

  • Front Desk Staff “Customer Service” At Previous Office

  • Want to take another step toward exceptional care? Please fill out:

    Personal Preferences Patient Communication E-Form

  • Summary

  • We appreciate your time expressing your past experiences and personal preferences. Your efforts will afford our team to ability to focus on your specific preferences and ultimately provide you with the best dental experience.

    If you are a New Patient

    You can fill out your new patient paper work now

    1. Patient Personal Information Form (Print, Fill Out & Fax or Email)

    2. Dental Insurance E-Form (Print, Fill Out & Fax or Email)

    3. Medical Health History E-Form

    4. Dental Health History E-Form

    If you have had a Bad Dental Experience, we strongly recommend you review

    Bad Dental Experience Patient Communication E-form

    Recommended Reading:

    1. Relaxation Techniques To Stay Calm During Dental Treatments

    2. Self Help Strategies to overcome Dental Pain & Fear

    3. Top 25 Dental Fears & Our Solutions “Facing Your Fears”

    For Those Seeking Exceptional Care, please fill out:

    Personal Preferences Patient Communication E-Form

    For Those Seeking Cosmetic treatment, its “Very important” that you fill out:

    Cosmetic Questionnaire


    What Happens Next

    It’s required that we keep your online information private and secure. Accordingly you will need to create and enter a 4-6 digit ID number on any E-form filled out on our site. Retain this 4-6-digit number as you will need to provide it to our scheduling coordinator. In turn, they will download your online information and save it to a new account hosted on our private secure server.

    Your best option is to call our office in advance of your appointment date. This will allow extra time for Dr Landers to review the E-forms you took your time to fill out.

    When you Call Please provide the Following E-form Information:

    1. First & Last Name

    2. The Names of E-Forms You Fill Out Online

    3. The 4-6 Digit Number You Entered On The E-Forms.

    We Will Use This ID Number To Attach Your E-Forms “Privately” To Your New Account At Our Office

    Contact Us Today! 312-263-7823

  • This Section MUST be signed in the office

    To the best of my knowledge all of the preceding information is true and accurate.

    Signature: _________________________________

    Print Name: _________________________________

    Date: ________________

  • Copyright Statement

    Advanced Cosmetic & Implant Dentistry, has exclusive rights under U.S. and foreign copyright laws. Unless otherwise indicated, all materials on these pages are copyrighted by the Advanced Cosmetic & Implant Dentistry inc. All rights reserved. No part of these pages, either text or image may be used for any purpose other than personal use. Therefore, reproduction, modification, storage in a retrieval system or retransmission, in any form or by any means, electronic, mechanical, or otherwise, for reasons other than personal use, is strictly prohibited without prior written permission.

    © Advanced Cosmetic & Implant Dentistry

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