New Patient Information

Below is a patient information packet. If you are coming to visit us for the first time, please complete it and bring it with you to your appointment or fax it back to us at 847-677-7432. If you have dental insurance, please bring your insurance card with you. We submit to all insurance companies, but we may not be an in-network provider for your plan. We do not participate in any HMO, DMO or discount plans. We will submit the claim for you and bill you the balance on routine visits. Major procedures may require advance co-pay.

To process claims, we need the name of your employer, a copy of your insurance card (front & back) or a completed claim form. There is also a page in the file below that is a records release form. By completing this form we will be able to obtain copies of your records from your former dentist.

Notice of Privacy Practices