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  • Medical Health History E-Form

    Please take a few minutes to fill out this form as complete as you can. Some sections must be completed in the office so you may not be able to fill them out online. If you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health.
  • Welcome

    All information provided is completely confidential.
  • / /
    Pick a Date
  • Yes No N/A
    Birth Control
    Pregnant? If yes, what trimester? _________
  • -
  • Yes No
    Within the past year, have there been any changes in your general health?
    Have you ever had complications following dental treatment?
    Are you currently under the care of a physician due to a specific condition?
    Have you ever been hospitalized within the last 15 years due to a surgery or illness?

  • Yes No
    Respiratory Problems
    Shortness of Breath
    Swollen Adenoids
    Heart Disease
    Heart Attack
    High Blood Pressure
    Low Blood Pressure
    Heart Surgery
    Chest Pain
    Take Blood Thinners
    Heart Murmur
    Mitral Valve Prolapse
    Artificial Heart Valve
    Used: Fen-Phen/Redux
    Congenital Heart Defect
    Rheumatic Fever
    Scarlet Fever
  • Yes No
    Frequent Vomiting
    Frequent Headaches
    Back Problems
    Cortisone Treatments
    Stomach Problems
    Blood Disease
    Excessive Bleeding
    Bruise Easily
    Daily Aspirin Therapy
    Sickle Cell Disease
    Blood Transfusion
    Artificial Joints
    Any Artificial Implant
  • Yes No
    Cosmetic Surgery
    Head Injuries
    Sinus Problems
    Chronic Headaches
    Pain In Ear
    Rheumatic Fever
    Hepatitis A
    Hepatitis B
    Venereal Disease
    Mental Disorders
    Nervous Disorders
    Received Psychological Care
    Take Antidepressants
    Chewing Tobacco
    Substance Abuse
  • Yes No
    Kidney Disease
    Thyroid Problems
    Liver Disease/ Jaundice
    Slow wound healing
    Radiation Treatment
    Epilepsy or Seizures
    Contact Lenses
    Reaction to Dental Anesthetic
    Osteomalacia (Rickets)
    Vitamin D Deficient
    Taken Fosamax
  • This Section MUST be signed in the office

    To the best of my knowledge all of the preceding information is true and accurate.

    Signature: _________________________________

    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 (Print, Fill Out & Fax or Email)

    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

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