Cosmetic History E-Form - Advanced Cosmetic Dentistry

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.
Your smile enhancement goals (Check all that apply)

Complete smile makeoverSmile enhancement (not a complete makeover)Minimally invasive treatment optionsHealth first treatmentNatural looking smileWhiter teethTreatments to achieve a perfect looking smileHollywood style smile makeoverInterested in only one specific type of treatmentTreatment focused only on a few teethTreatment for pain or discomfort onlyFast dental treatment options (2-8 Weeks)Same day care for a particular dental problem
Optional – If this smile enhancement procedure is for special occasion, please let us know the date you would like to finish by?
How did you find us? (Check all that apply)

Personal recommendationSearched for Dentists “Near Me”Referral from a another doctor’s officeReferred by a Professional dental organizationAmerican Academy of Cosmetic Dentistry (AACD)Reviews -YelpReviews -GoogleYoutube (videos)Our before & after imagesInternet search
Optional -If you found us on an internet search, please include the key words you searched to find us?
How did you prepare for your cosmetic consultation? (Check all that apply)

I do a lot of online researchI read books about dentistry i.e. Billion Dollar Smile or other guidesI have consulted with several other dentistsI have had many dental treatments over the years. At this point, I consider myself proficient in dentistryI have a personal friend or family member who is a dentist or lab technician who advises me.I worked in the dental profession or currently work in the dental professionNone of the above
What do you like most about our website (Check two)

Before and After picturesDr Landers’ training and credentialsFinding one dentist for all your needsSpecialized treatments offeredWritten patient reviewsReal life stories (patient videos)Personalized communication formsBeneficial topics & content on our websiteNot sure yet
Regarding causes of your dental problems (Check all that apply)

My enamel is soft and I seem to get a lot of cavitiesI have problems with my salivaI need to be better with my home care. I don’t brush or floss often enoughI rarely brush afterward sugary foods & snacksI don’t brush my teeth before I go to bedI have medical conditions which cause dental problemsI am inherently disposed / my dental problems are geneticI take medications that cause dental problemsMy parents did not take me to the dentistI’ve always had poor quality dental careI have dry mouthI have a uneven, unbalanced – bad biteI grind my teethMost of my problems are result of bad dental treatmentsMy problems were caused by another DentistI have more problems then the average person but I have no idea whyI think my dental problems are normalHistory of a past traumaNone of the above
If your dental problems were caused by trauma, please describe the trauma and provide the dates:
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.
Metal fillings vs White plastic fillings vs White porcelain fillings: (Check all that apply)

I do not want any metal fillings. Even if they are stronger, last longer, and statistically cause less post treatment sensitivity then white plastic fillingsIf a metal filling is better, I don’t mind a metal filling on a tooth or a location that is difficult to seeCost and/or insurance coverage are not my main concern. Nonetheless, I would like a cost /benefit of each type of filling explained to meMetal, white plastic, or porcelain, it does not matter to me. I would like the filling material that lasts the longest, causes the least amount of post treatment sensitivity, and best protects my tooth from root canals or breakageCost is not my main concern, health & protecting my tooth are most important to me. I would like a quote for the best dental material for each specific situationI am not concerned about how long a filling will last or what color it is. I would simply like the least expensive filling options. I would like the filling my dental insurance will most likely coverI have a general dentist who handles my fillingsI’m not interested in changing any fillings at this timeNone of the above
Your smile design expectations (Check all that apply)

I am not trying to have 100% perfect resultsI’m a perfectionist; I refuse to accept any standard short of perfectionI want as close to 100% perfect results as is be humanly possibleI have high expectations, but I understand that achieving 100% perfect results may not be possibleI just want smile enhancement. I am seeking an improved smile not a perfect smileI am seeking optimal results based on my current conditionI am not worried about how my smile looks, as long as I am healthy and it’s comfortable to eatNone of the above
What best describes the specific type of smile you are seeking: (Check all that apply)

I want the greatest level of regularity between teeth shape, size and alignmentI want the maximum level of whiteness/brightnessI want an amazingly beautiful “Hollywood Smile” & don’t mind if some people don’t believe it looks realI want a beautiful smile that is as white & bright as possible with out looking too fake. My goal is that most people think it looks realI want a “beautiful & a little whiter smile, but not perfect. I’m going for the more subtle look”I want a natural looking smile that looks clean and healthy. I’m not apposed to slightly whiter teeth, but I am seeking a more natural lookI don’t want whiter teeth. I just want dental restorations to match my existing teethI am not worried about all of the imperfections that I see close up, but others mostly don’t notice. The smile enhancements perceivable by others from conversational distance are most important to meI am not interested in cosmetic dentistry, as long as I am healthy and it’s comfortable to eatI’m seeking to restore the look of my old smile. I will bring close-up pictures of my old smileI have pictures of another person’s smile as an example of what I likeNone of the above
If you have pictures of another person’s smile. (Check all that apply) If you don’t have pictures, skip to the next question.

I only want a doctor who is skilled enough to give me the exact smile in my picturesI have brought pictures of another person’s smile as an example of what I like. I understand these images are of a smile that is anatomically different then my own smile. Considering the latter, I understand that some of the anatomical details might not be achievableI brought smile images of other people so that I could point out what I like. Please explain how my existing pre-treatment condition will affect Dr Landers’ ability to achieve my goals and desiresI know that no doctor or professional for that matter can promise perfect results. I am simply looking for a doctor who will give me the best chance of having my own personal best smileI don’t have pictures of another person
*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.
Smile design IQ vs. Patient-Doctor communication (Check all that apply)

I know exactly what I want and I am seeking a doctor who can confidently delivery my desired resultsI can’t explain exactly what I want; I’m hoping to find a doctor who can help me to explain what I wantI am interested in learning about how my current condition will affect the final results of my smile makeoverNone of the above
Treatment predictability (Check all that apply)

I understand that in order to achieve excellence, I will need to be flexible in the event my needs change over the course of treatments. I understand that additional time and visits may be neededIf I am paying for high quality care, I strongly believe that the treatment results should be predictable for each and every step of treatment. I don’t have extra time and I don’t feel I should have to return to correct problems that were not predicted at the beginning of treatmentIf treatment is not done right the first time, I will stop all dental treatments and will typically stop going to the dentist who caused the problemNone of the above
Your past experiences with smile design (Check all that apply)

I was shown a smile design on a computer screen, but I was unhappy with the final result. My final smile did not look like the computer animationThe Dentist “farmed out” my smile design to a dental lab technician I have never met. My teeth models were sent in the mail and the dental tab returned wax version of my smile. The dentist reviewed the wax version of my new smile with me, but I ended up unhappy with the final results. My new smile did not look like my temps or the lab wax-upThe dentist took a digital scan of my teeth and used smile design software to create my smile, but I was unhappy with the final new smile. It did not look like the computer animationThe dentist did not do smile design at all and I was unhappy with my final new smileNone of the above
List of possible dental problems

Check off any that apply to you
Orthodontics:

Uneven Teeth LengthLong Teeth Over eruptionShort Teeth Under EruptionMisaligned TeethCrooked TeethCrowded TeethOverlapping TeethMoved Back After BracesMoved Back After InvisalignEctopic EruptionTeeth GapsSpaces Between TeethDiastema ClosureBlack Triangles Between TeethInterdental Papillae MissingMidline Not CenteredMidline Canted /AngledTooth Axis Of Inclination OffSmall TeethBig TeethBad Tooth Shape /ProportionOverbiteUnder BiteDeep BiteCross BiteEdge To Edge BiteOverjetUnderjetOpen BiteTongue Trust /Tongue PostureTeeth Tipped Forward /Buck TeethBite Collapse (Virtical Closure)Missing Teeth in BackWisdom Teeth Vs. Teeth ShiftingTooth Keep MovingDid Not Wear RetainerRetainer Broke Teeth ShiftedRoot Resorption (Short Roots)Internal Root ResorptionExternal Root Resorption*Molar -Uprighting Tipped Tooth*Move Tooth to Create Space for ImplantMalaligned Upper Or Lower JawsUpper Jaw Bone Too Far Back Or ForwardUpper Jaw Tipped Up in FrontUpper Jaw Slanted –Higher on Left or right Crooked SmileLower Jaw ForwardLower Jaw BackLower Jaw shifted too far Right or leftNarrow Arch FormDark Buccal CorridorUpper Arch too wideMouth BreathingBraces take too long
Implant:

Missing TeethMissing Front ToothMissing Back ToothLoose Teeth, Tooth MobilityLoose Sore DentureCongenitally Missing Later IncisorsRetained Baby ToothMaryland Bridge (Resin Bonded) Keeps Falling OutRoots Too close for Dental Implant placementBone LossBoney DefectsIndentations In Gums & JawboneBony Dehisence & Fenestration under GumsOsteoporosisNot Enough Bone For ImplantInfected Dental ImplantsPeri-implantitisImplant Screw LooseLoose Dental ImplantImplant Rejection FailureImplant Tooth Looks Bad FakeImplant Shows Through Grey CrownDark Implant CrownsImplants Treatment Takes too LongFast Implant TreatmentsSame Day Implant Teeth
Cosmetic Restorative:

Chipped ToothCracked TeethTeeth Lines/CracksCracked RootHoles In TeethTeeth Pits From Acid ErosionBroken ToothBroken /loose Dental CrownBroken Porcelain VeneerBroken /loose Dental BridgeBroken /loose FillingTooth Cavities /Rotten TeethWorn TeethOld TeethWeak Tooth StructureLeaky Dental WorkPoor Tooth Quality & QuantityDental Crown Keeps Fell outDental Bridge Keeps Fell outPorcelain Veneer Fell outFilling Fell OutReplace Bad Fake DentistryFake bad Color MatchBad Fake Metal BridgesBad Fake CrownsBad Fake Porcelain VeneersReverse Smile Teeth Edge LineSmile teeth Edge Line Not level with FaceSmile teeth Edge Line not level with lipsSmile Teeth Edge Line Worn FlatLow Lip Cant See My TeethHigh Lip Too Much GumsSmall Teeth SmilePeg LateralsMissing Laterals Canine SubstitutionRoot Surface Cavity /LesionRoot AbfractionDark FillingsSilver FillingsMercury SensitivityBlack Line At GumsDead Grey ToothRoot ResorptionBite Closure & CollapseChipping, Breakage, Wear & Movement Due To: Day Time HabitsChipping, Breakage, Wear & Movement (Bite Changes) Due To: Night Time Grinding Or Night Time Oral Appliance (Sleep Apnea Appliance)Acidic Breakdown Of Tooth Structure: Bulimia, GERD, Acidic Diet
Surgical

Bone LossDark GumsBony DefectMissing Interdental PapillaeSmall Teeth SmileGummy SmileUneven Gum LineAttached Gum ThinGum Recession from Tissue PullReceding GumsRoot ExposureCrown Margin ShowsSensitive Tooth RootLong Front TeethGum DefectCavity Below GumsBroken Tooth at or Below GumsBony Ridge Exostosis & ToriFailing Root CanalBone Infection At Tip Of RootBone CystPimple On GumsBleeding GumsPeriodontitisLoose Mobile TeethTrench MouthBlack TriangleWisdom Teeth Pain SwellingImpacted ToothTooth Pain & Sinuses
Color/ Enamel Defects

Stained TeethDiscolored TeethYellow TeethGrey TeethFood StainsCoffee Or Tea StainsDead ToothDead Tooth NerveEnamel DefectsAntibiotic StainingWhite Spots On TeethHypo CalcificationHyper CalcificationAmelogenesis imperfectaFluorosisThin Worn EnamelThin Chipping Sharp Tooth EdgeFix Old Bad Fake DentistryOld Yellow BondingPoor tooth Color MatchMetal Post Front ToothTooth Cavities /Rotten TeethSpaces Gaps Black TrianglesYellow CrownsDark Grey CrownsDental Plaque /CalculusWhiten VeneersExposed Yellow Tooth Roots
TMJ/ OcclusionJaw joint (TMJ) pain

Bad BiteImpingement of Lower Teeth & jaw behind upper teeth.Occlusal (Tooth to tooth) TraumaAvoidance pattern/ Functional shiftBite Doesn’t Feel NormalPain soreness and Top & bottomRoot Canal Gone BadApicoectomy Didn’t WorkMigrainesHeadachesFacial Muscle PainClenchingGrindingJaw pain After New Dental WorkPain or tenderness in your face, jaw joint area, neck, shoulders, and around ear.Bite Collapsed From Degenerative Jaw JointLack Of Canine/Lateral GuidanceSleep Apnea And Snoring
Psychological

The Aging SmileLook Younger Smile MakeoversPosition Or Shape Of Your Teeth/CrownsTreatment Took Too LongBad Dental ExperienceSecond OpinionDental Anxiety & PhobiaOld Outdated DentistryHealthy TreatmentsDental PhobiasCost Of Dental TreatmentInsurance Decreased Or Non PaymentHollywood WhiteMinimally InvasiveHealth First Dentistry
Emergency Problems

Broken Sharp ToothOral CancerCanker SoresOral HerpesAmthus UlcersBurning Mouth/TongueDry Mouth SyndromeBleeding GumsSwollen GumsAbscess GumAbscessed ToothGum Disease /Periodontal DiseaseTooth SensitivityTooth PainFood ImpactionTooth AchesThumb SuckingParafunction Day/nightBraces Bracket Loose BrokenLost Invisalign TrayRetainer Wire BrokeWire Pocking
Causes Of Problems

Dry MouthSleep ApneaDaytime HabitsNighttime HabitsPoor Oral Hygiene
Denture

Lower Denture ProblemsLoose DenturesBroken DentureBroken Lost Denture ToothBroke Denture Clasp Or AttachmentDenture Pain When EatingDenture moves when speaking
List any dental problems you did not check off in the list above .

Please check all procedures and treatments below that you may consider for treatment. This section is highly recommended. If you don’t have an opinion or if you’re not sure, check the radial button next to "Need More Info to Decide." Do your best, you can always change your mind later.

	1st Choice	2nd Choice	3rd Choice	Maybe (I want more info)	I don’t want this	Need More Info to Decide (Please share more info about this service)
Porcelain Veneers
Dental Bonding
Porcelain Crowns
Dark Grey Dead Tooth Treatment
Tooth Supported Dental Bridge (Front teeth)
Tooth Supported Dental Bridge (Back teeth)
Dental Implant to Replace Old Bridge
Full Mouth Reconstruction
Smile Tune Up (For People Seeking Minor Improvements Only)
Gummy Smile Treatments
Level Uneven Gum Line
Gum Graft & Root Coverage
Laser Gum Treatments
Invisalign
Clear Teeth Aligners (4-8 Wks)
Clear Braces
Fast Surgical Orthodontics
Metal Braces
Save Teeth with Gum Surgery & Restorative Treatments
Extract Teeth & Replace with Dental Implants
Bone Grafts for Dental Implants
Dental Implants Front Teeth
Dental Implants Back Teeth
Implant Bridge Front Teeth
Implant Bridge Back Teeth
Full Upper Or Lower Implants
Teeth In A Day (Implants Bridges)
All On 4 or 6 Implant Bridges
Computer Guided 3-D Implant Surgery
Implant Retained Denture
Denture with No Implants
In office Laser Teeth Whitening
Professional Take Home Whitening
Whitening for Life
TMJ Joint & Bite Therapy
Mouth Guards /Daytime Habit Appliances
Sleep Apnea Appliance
White Fillings
Metal Fillings
No Needle Drill Less Fillings
All Porcelain Crowns Back Teeth
Porcelain Fused to Metal Crowns
All Porcelain Onlays
Routine Dental Cleaning
Fresh Breath Treatment
Computerized Root Canals
Wisdom Teeth Extractions

If not already address from the list above, please list any additional dental procedures you are seeking to correct you dental problems:
*Optional – In your own words, share how your ideal smile would look. Please include location of problem.
Patient preferences regarding tooth shaping & preparation (Check all that apply)

I would like to be offered cosmetic treatment options that do not involve or require any tooth removal. I understand that my request to not allow tooth removal could affect the final outcome of my treatment (i.e. less optimal cosmetic results)Please offer options, which allow for minimal tooth removal. I understand that my request to not allow tooth optimal removal may affect the final outcome of my treatment (i.e. less optimal cosmetic results)I really would like an amazing smile. I agree to remove the amount of tooth structure that is required and suggested based on dental industry standards. I understand that Dr Kevin Landers implements all modern day techniques to accurately shape and prepare my teeth for dental restorations. Including fabrication and use of a reduction matrixIf tooth structure needs to be removed to improve aesthetics, I agree and trust Dr Landers’ judgment. In other words, I want Dr Landers to shape my teeth as needed so I can have the most predictable cosmetic resultsClear teeth aligners move teeth fast (4-6 weeks) and decrease the need to remove tooth structure. If the latter is true, I prefer to move my teeth before they are shaped for dental veneers or crownsNone of the above
Patient preferences regarding how teeth, which are tipped forward affect the final look of porcelain veneers. (If your teeth are not tipped forward skip this question)

I don’t mind that my teeth or if the final Veneers are tipped forwardI don’t want my veneers to be tipped forward. I don’t like the “buck teeth” lookI don’t want veneers which are too bulky lookingIf I choose to do multiple veneers, I don’t want an uneven color match. I would like all of the dental veneers to be similar in color and brightnessMy teeth are tipped forward, I don’t want orthodontic treatment to move my teeth, I don’t want my tooth structure removed, and I don’t want my final veneers tipped forwardNone of the above
Treatment options for patient with teeth that are tipped forward: (If your teeth are not tipped forward skip this question). If my goal is to end up with straight looking teeth which line up in a ideal cosmetic arch form and look good from the side (profile): If my tooth or teeth are tipped forward:

I would like to tip my veneers or crowns forwardPlease remove the portion of the tooth, which is tipped forward, and then cover it with the veneer or crown. I want straight looking teeth after treatmentClear teeth aligners move teeth fast (4-6 weeks) and decrease the need to remove tooth structure for teeth tat are tipped forward. If the later is true, I prefer to move my teeth before they are shaped for dental veneers or crowns
What’s most important to you (Choose one)

CostTimeHealthOptimal Cosmetic Results
1 2 3 4 5

1 is At this time cost of treatment will dictate what I choose , 5 is I'm seeking the best treatments available
1 2 3 4 5

1 is I only want treatments that are 100% covered by Insurance , 5 is I will pay more “Out of my pocket” for better dental care. Even if insurance does not over the cost.
1 2 3 4 5

1 is I'm mostly seeking cosmetic treatment , 5 is My priority is healthy treatments. Cosmetic treatments are of secondary importance to me
1 2 3 4 5

1 is Put me to sleep for all dental treatments , 5 is I prefer to try and manage my dental Apprehension

	1	2	3	4	5

1 is I want to know step by step details during clinical treatments , 5 is After a doctor has gained my trust, I like to relax during dental treatments. I do not want Step by Step Details unless it’s really important

1 2 3 4 5

1 is I like to make all of my own decisions , 5 is If I find a trusted expert, I like to defer a doctor’s profession option

	1	2	3	4	5

1 is I want the maximum safe amount of dental anes needed to assure I will not feel anything , 5 is I want very little to no dental anesthetic. If If feel something I will raise my hand

1 2 3 4 5

1 is Please provide prescription strength pain reliever , 5 is I don’t like taking prescription strength pain relievers. Please recommend an over the counter solution

	1	2	3	4	5

1 is I don’t mind taking antibiotics. Offer me antibiotics even if there is a small chance for a post treatment infection, 5 is Only offer antibiotics when there is a higher statistical chance for infection or when Dr feels it's necessary

1 2 3 4 5

1 is I’am prone to dental infections , 5 is I heal quickly
1 2 3 4 5

1 is My work schedule is very important , 5 is My health is more important then my work schedule

	1	2	3	4	5

1 is I talk a lot at work and can’t be numb during working hours. Use little or no anestheti , 5 is I don’t want to feel pain during dental visits. numb me, It's okay if I stay numb for several hours after dental treatments

	1	2	3	4	5

1 is Age mature patients should not Investing time and money in high quality dental care. , 5 is Old or young, it does not matter. Dental health, fresh breath, comfort, and the ability to eat is very important at any age

1 2 3 4 5

1 is Older folks don’t need to look good , 5 is Looking good is a personal preference & the desire to look good is admiral at any age
1 2 3 4 5

1 is I’m a Perfectionist , 5 is I like to go with the flow
1 2 3 4 5

1 is It's appropriate to look well groomed, but I think society relies too much on physical appearance , 5 is Physical appearance is very important to me

	1	2	3	4	5

1 is “I like to do my own research: I want to review all of the treatment details with the doctor. Then I will decide on treatment options, 5 is I prefer to spend the time with the goal to find a professional & then “trust the doctor to decide"

1 2 3 4 5

1 is I want whiter teeth , 5 is I want natural looking teeth to match my existing color
1 2 3 4 5

1 is I want a Hollywood White Smile , 5 is I’m seeking to improve my smile. I don’t want to spend time or money on a perfect smile

	1	2	3	4	5

1 is Regarding dental restorations, ie Crowns and Veneers, I refer a monolithic look: i.e. Little to no yellow root stain or chewing edge grey transparency, 5 is Regarding dental restorations, i.e. Crowns and Veneers, I prefer teeth with numerous color variations and varying translucency

	1	2	3	4	5

1 is Because back teeth are more difficult to see, I not seeking prefect cosmetic results. Please use life-like tooth colored dental fillings and Crowns, but lean toward the longer lasting materials, 5 is I want dental crowns and fillings on my back teeth that are aesthetically as close to perfect as possible. Even if its more expensive, takes longer, and may not last as long

Question’s vs Insurance (Check the statement that best fits)

It’s my understanding that my dental insurance covers 100% for most all dental proceduresI don’t know the amount if any that my dental insurance covers please estimate for meI don’t know the amount if any that my dental insurance covers. please help me to maximize and estimate my benefitsI would like to have the highest quality care and the longest lasting treatment. Please give me a cost estimate to maximize my insurance coverage but please do not make decisions based on insurance limitationsAt this time of my life, I am insurance dependent. I do not want any dental care which is not covered by my dental insurance even if my insurance only covers outdated materials or old techniquesI have great insurance and I think it will cover most of treatment costsNone of the above
Q’s vs Time (Check the statement that best fits)

I am willing to wait; it waiting gives me the best odds to achieve optimal healthy resultsI want all treatment completed before X dateI want my most beautiful smile, but I want all treatment completed by dateI am very busy. If treatment takes too long, then I would rather not complete that recommended treatment
Treatment Specific Questions

The following questions are optional. Only answer questions if it relates to the specific treatments you are seeking.
Surgery preferences (Check all that apply)

I want to avoid any type of surgeryWill agree if it has a health related benefitWill agree if there is a significant cosmetic improvementWill agree if it’s not too expensiveNone of the above
Night time grinding (Check all that apply)

I’ve been told that I grind my teeth by another dentistI am 100% certain I grind my teeth because I have caught myself and/or my spouse has observed me grinding at nightI often wake up with sore jaw musclesI often have sore jaw muscles during the dayI don’t have a grinding applianceI have an over the counter grinding applianceI don’t like wear a grinding applianceNone of the above
Fillings Options
Metal Fillings

I do not want any metal fillingsI don’t mind a dental filling positioned on a tooth or area where it is not commonly visibleDoes not matter if it’s metal or if it’s a white tooth colored restoration. I want the type that lasts the longest and best protects my tooth from root canals or breakage
Orthodontic Q’s
What best describes your personal preference regarding wearing braces for tooth movement.

I will wear braces as long as 2-3 years if neededI will wear braces for a short period of time if there are no other optionsI will wear braces, but only as a last result. I am mostly interested in clear teeth aligners or InvisalignI will not wear braces. This simply is not an option I would chooseNone of the above
If there is a benefit of porcelain braces I will only wear them for:

2-months4-months6-months12-monthsI want to try clear teeth aligners first, but agree to switch to porcelain braces for a short period of time if neededI will not wear porcelain bracesNone of the above
My teeth moved after braces because (Check all that apply)

I received poor quality treatmentI did not wear my retainerMy tooth to tooth bite forces never felt right after treatmentI have a tongue thrust habit or posture my tongue forward between my teethI’m a mouth breatherNone of the above
Dark Grey Tooth Treatments
If you have a dark grey tooth and want treatment (Check all that you believe to be true)

Natural looking results are 100% predictable if you choose the right dentistTeeth can be dark for many different reasons. The type of problem will affect the predictability of treatmentIf the tooth root is black under my gums, it will create a shadow above my tooth. The type of porcelain chosen for the final crown may not change this shadow above my toothMatching a porcelain crown to a adjacent natural teeth requires extra dental visitsMatching natural teeth requires that the dentist hire and excellent dental lab which is commonly more expensiveNone of the above
Thicker dental porcelain is required to mask a dark tooth (Check off your preference)

I’m only seeking an improved smile. I don’t expect that all of the dark color will be masked or blocked with the new crown. I don’t want to remove additional tooth structure in addition to what is normally required during Porcelain Crown preparation. Even if it means I will end up improving cosmetic results, I do not want to weaken my tooth in any wayI really want the best possibility of achieving perfect results, even if it means removing additional tooth structure. I will agree to orthodontic tipping of my tooth backwards with clear teeth aligners if neededI don’t want to remove more tooth structure but am willing to except a slightly thicker looking or bulky crown to mask the dark colored toothNone of the above
Front Teeth Wear & Dental Bonding Chipping
The wear on my front teeth is from: (Check all that apply)

Grinding at nightSubconscious daytime habitsAnother dentist shortened or shaved them downTraumaI don’t know
Would you like help regarding financing your procedure?

YesNo
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
Check to indicate the E-forms you filled out on our website:

Patient Personal Information Form (Faxed to: 312 263-7013)Dental Insurance E-Form (Faxed to: 312 263-7013)Medical Health History E-FormDental Health History E-FormCyber Consult *Send X-Rays & ImagesPersonal Preferences Patient Communication E-FormPain Management Patient Communication E-FormBad Dental Experience Patient Communication E-FormPatient Satisfaction Survey E-Form
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
To keep your information private and secure, please enter a 4-6 digit ID number of your choice below. Retain this 4-6 digit ID number as you will need to provide our office staff with that number during your appointment so we may retrieve your submission. You may also call our office beforehand and provide us with that number.*
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
ChicagosCosmeticDentist.com
312-263-7823
Should be Empty:

Cosmetic Questionnaire E-Form

List of possible dental problems

Treatment Specific Questions

Summary