Call: (847) 669-4771

Patient Forms

  Please click on a link below to fill out and submit your dental forms before your appointment

New Patient Forms Packet

Medical History Update Form


            As a service to our patients, our practice accepts most dental insurance programs, including indemnity (traditional) and PPO.  We are not part of any managed care (HMO) networks.  Our staff will prepare and submit 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. For treatment with higher anticipated copayments, our staff will gladly submit a pre-treatment estimate to your insurance company so that you will know 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.

Payment Options

       We accept cash, personal checks, major credit cards and Care Credit. Payment is expected at the time services are performed. When more extensive dental care is necessary, financial arrangements can be made.

 Thank you and please contact our office if you have any questions. We look forward to meeting you!

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