loader image
  • Dental Health History E-Form

    Please take your time and fill out as much of this form as possible. Due to HIPPA Privacy Laws, some sections cannot be filled out online and can only be completed in the office. If you have questions we'll be glad to help. We look forward to working with you.
  • / /
    Pick a Date
  • / /
    Pick a Date
  • / /
    Pick a Date
  • Yes No N/A
    Do you currently wear a removable dental appliance at night or during the day?
    Do you currently have any dentures, flippers or partials?
    Do you frequently get cold sores, blisters or other oral lesions?
    Have you experienced complications after dental treatment?
    Would you like to keep your teeth the rest of your life?
    Are you interested in Fresh Breath Treatments ?
    Do you routinely use a Waterpik or water flosser
  • Yes No
    Jaw Joint Problems TMJ / TMD
    Popping & clicking of the jaw
    Recurring Pain around your ear, or side of face
    Jaw muscle pain or soreness when you wake up
    Jaw muscle pain or soreness later in the day
    Serious injury to teeth, mouth or jaw
    Experience Sinus Problems
    Recurring migraines or Headaches
    Change in your bite
    Clinch during the day
    Grind at night
    Bite Therapy or Adjustments
    Sleep apnea or Sleep disorders
    Wear CPAP at night
    Wear Dental Snoring Device
  • Yes No
    Tell me about snoring treatments?
    I’m happy the way my teeth look when I smile
    I’m happy with the color of your teeth
    Have you ever had braces?
    Have you ever worn Invisalign?
    Did your teeth move back?
  • 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. Dental Insurance Information Form (Print, Fill Out & Fax or Email)

    3. Medical 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

  • 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

  • Should be Empty:
WordPress Image Lightbox Plugin