• Cosmetic Questionnaire E-Form

    If we are to make recommendations centered on your goals and desires, your help is essential. Please take a few minutes to fill out this form as complete as you can. We look forward to working with you in maintaining your dental health.

  • Fillings Preferences

    Please Read the following before answering the next question:

    1. White plastic fillings have a natural tooth color, are great for anterior teeth & smaller shallow cavities in molar teeth. White plastic fillings are not ideal for larger fillings on posterior crushing and chewing molars.
    2. Silver Metal fillings are stronger, cause less chance of after treatment sensitivity, are less expensive, and last longer then White Plastic fillings on crushing chewing molars.
    3. Porcelain fillings (dental porcelain onlays) are made of a strong tooth colored material that lasts longer then metal, or white plastic fillings. The benefits of using a porcelain filling increases, as the size of the filling gets larger. The down side of a porcelain filling is that they are the most expensive type of dental filling.

  • *If you are seeking to restore your smile, we encourage our patients to bring close up, high quality pictures of their old smile before any dental problems.

  • List of possible dental problems

    Check off any that apply to you

  • Image

  • Treatment Specific Questions

    The following questions are optional. Only answer questions if it relates to the specific treatments you are seeking.

  • Fillings Options

  • Orthodontic Q’s

  • Dark Grey Tooth Treatments

  • Front Teeth Wear & Dental Bonding Chipping

  • 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: ________________

  • 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. Medical Health History E-Form

    3. Dental 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:

    7-Steps Proven To Reduce Dental Fear & Anxiety

    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

    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

  • 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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