• 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 these 3 Filling Facts before answering the following question:

    1. Silver Metal fillings are stronger, cause less post treatment sensitivity, less expensive, and last longer then White Plastic fillings.
    2. Porcelain fillings (dental porcelain onlays) are made of a strong tooth colored material that lasts longer then metal, or white plastic fillings. The benefit of using a porcelain filling increases, as the filling gets larger.
    3. 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
  • Top 10 Hidden Dangers You Will Encounter Completing Cosmetic Restorative Dentistry

    1. Weak Tooth (Ferrule)

    2. Black Tooth

    3. Lack Of Canine/Lateral Guidance

    4. Bone Defects: Dehisence & Fenestration

    5. Occlusal Trauma Vs Tooth Mobility

    6. Cracked Tooth

    7. Insurance Non Payment

    8. Malocclusions: Class III Deep Bite, Open Bite, Bite Collapse, Degenerative Jaw Joint

    9. Parafunction

    10. TMD

    For Dental Problems Related To Dental Emergencies, Please See Our Dental Emergency Self Help” Section On This Site Or Call Our Office.

    Front Page Emergency Topics * Each Topic Will Have To Be Outlined Vs. Problems 2017

    #1 Knocked Out Or Loose Tooth

    1. Intro Knocked Out Or Forced Loose Tooth.Doc

    2. Knocked Completely Out.Doc

    3. Knocked Inward Into The Tooth Socket.Doc

    4. Knocked Loose & Still In Position.Doc

    5. Knocked Out Of Position.Doc

    6. Loose Children's Baby Teeth.Doc

    #2 Broken-Chipped Tooth And Or Lost Filling

    #3 Tooth Ache

    #4 Injuries Soft Tissues Of Mouth & Jaw

    #5 Common Mouth Sores

    #6 TMJ Or Grinding Pain Or Migraine Pain

    #7 Swollen Infected Face, Gums, Or Wisdom Teeth

    #8 Loose Permanent Crowns Or Temporaries

    #9 Emergencies After Surgical Procedures

    #10 Emergencies After Routine Dental Procedures

  • 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
  • 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:

    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
    ChicagosCosmeticDentist.com
    312-263-7823

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