Patient Information - Forms

Appointment

The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office in Lake Bluff, IL, by phone or complete an online appointment request.

Patient Forms

If you are a new patient to our office, the attached file contains our new patient bundle with forms that will need to be filled out when you arrive at our office. Printing them, filling them out and bringing them with you will allow us to attend to your dental needs more quickly than completing them upon your arrival. Thank you and please call our office if you have any questions at all.

Patient Information Form

Dental/Medical History Form

New Patient Form - Children (Pg 1.)

New Patient Form - Children (Pg. 2)

HIPPA and Contact Info Forms

Payment Options

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Pay Now

For your convenience, we accept cash, personal checks, money orders, and most major credit cards. Payment is expected at the time services are performed.  Feel free to contact our office If your treatment plan requires more comprehensive dental work and you want to discuss financial arrangements.

   
Dental Insurance

As a service to our patients, our practice accepts most dental insurance programs, including non-managed care, indemnity (traditional) and PPO out-of-network. We are not part of any managed care network. Our accounting staff will electronically prepare and file all the necessary forms for your dental benefits. However, we remind you that your specific policy is an agreement between you and your insurance company. Please keep in mind that you are responsible for your total obligation should your insurance benefits result in less coverage than anticipated. Our staff will gladly submit a pre-treatment estimate to your insurance company so that you will now what your benefits will be. 

The fees charged for services rendered to those who are insured are the usual and customary fees charged to all our patients for similar services. Your policy may base its allowances on a fixed fee schedule, which may or may not coincide with our usual fees. You should be aware that different insurance companies vary greatly in the types of coverage available. Also, some companies take care of claims promptly while others delay payment for several months. We will do everything possible to make the financial aspect of your care as painless as the dental care itself!