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  • Patient Personal Information Form

    We are pleased to welcome you to our practice. Please print this form and fill it out as complete as possible. Due to HIPPA Privacy Laws, some sections cannot be filled out online. Please fax the completed form to (312) 263-7013 or you can bring it in with you to your scheduled appointment. If you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health.
  • Patient Information

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  • Responsible Party

    (If applicable)
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  • Patient Authorization to Release Confidential Information

    This authorization is optional, but MUST be signed in the office if you wish to release information to a specific person.
  • I, (Patient/Guardian) __________________________, hereby request and authorize Advanced Cosmetic & Implant Dentistry to disclose and provide copies of any and all clinical treatment records and information concerning my care, which is in the possession of Advanced Cosmetic & Implant Dentistry, to: (Name of Parent/Spouse/Person you wish to release records to) ___________________________________.

    Relationship to patient: ______________________

    These records include, but are not limited to: personal patient information, medical and dental histories, examination records, radiographs, clinical photographs, treatment plans, treatment records, referral and consultation recommendations and reports, diagnostic models, and or related materials. I expressly release from liability Advanced Cosmetic & Implant Dentistry, Dr Kevin Landers, and its employees from any and all liability arising from compliance with this request and disclosure of the requested information.

    Patient/Guardian Signature: ___________________________________

    Date __________

  • Patient Dental History

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  • Patient Medical History

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    Arthritis, Rheumatism
    Artificial Heart Valves
    Artificial Joints
    Back Problems
    Blood Disease
    Chemical Dependency
    Circulatory Problems
    Cortisone Treatments
    Cough, Persistent
    Cough up Blood
    Heart Murmur
  • Yes No
    High Blood Pressure
    Jaw Pain
    Kidney Disease
    Liver Disease
    Mitral Valve Prolapse
    Radiation Treatment
    Respiratory Disease
    Rheumatic Fever
    Scarlet Fever
    Shortness of Breath
    Skin Rash
    Swelling of Feet or Ankles
    Thyroid Problems
    Tobacco Habit
    Venereal Disease
  • Referral Section

  • 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. Insurance Plan Information

    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

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