loader image
  • Dental Insurance 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.
  • Primary Dental Insurance

  • Please enter the primary dental insurance information and insured person’s information below:

  • / /
    Pick a Date
  • / /
    Pick a Date
  • Secondary Dental Insurance

  • Please enter the secondary dental insurance information and insured person’s information below:

  • / /
    Pick a Date
  • / /
    Pick a Date
  • This form MUST be signed in the office


    I certify that I, and/or my dependent(s), have insurance coverage with (Name of Insurance Company(ies)) ________________________________________ and assign directly to Dr. Kevin Landers all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

    The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.


    Patient/Guardian Signature




    Please print name of Patient/Guardian


    Relationship to Patient

    Payment is due in full at time of treatment unless prior arrangements have been approved.

  • 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

    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