• (630) 541-8374
  • 519 N. Cass Ave, Suite 102, Westmont, IL 60559
    101 E. St. Charles Road, Suite 101. Villa Park 60181

Patient Forms

Please Complete Prior To Your Appointment

Please click on the following forms to print and bring to your first appointment. You may also complete the smile assesment (not required).

Patient Registration

Medical History


 


Smile Assessment

Your smile has a lot of effect on your overall self-confidence and social interaction. Lots of people are afraid of smiling or laughing. You can easily assess your smile by answering the following questions. Stand in front of the mirror, make a wide smile, and try asking yourself these questions:

 

Do you have stained, yellow or discolored teeth?

YesNo


Would you prefer whiter teeth?

YesNo


Are there gaps between your teeth?

YesNo


Do you have crooked, turned, or uneven teeth?

YesNo


Are any teeth missing?

YesNo


Are there visible defects on the teeth surface?

YesNo


Are teeth edges uneven, chipped or worn down?

YesNo


Do your teeth appear too long, large or small?

YesNo


Have had any unnatural dental work?

YesNo


Are there dark-like bridges or crown at the edge of your gums?

YesNo


Are there any silver, black or gray fillings in your teeth?

YesNo


Do you have too much of your gum showing when smiling?

YesNo


Do you have puffy, bleeding, red or receding gums?

YesNo


Are you discouraged from smiling or laughing because of the appearance of your smile?

YesNo


Do you smile with lips closed when photographed instead of putting up a broad smile?

YesNo


Are you concerned about your smile or teeth?

YesNo


Is there anything you would like to change about the appearance of your smile and teeth?

YesNo


If your answer to any of the above questions is YES, there are various solutions with which you can improve your smile and teeth. If you want us to personally respond to your smile analysis, please fill out the form below.

You can finally possess the smile of your dream! Get in touch with us today to schedule a to schedule an appointment



Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.

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