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Associated Dental Care proudly provides dental services to Bloomingdale, Carol Stream, Glen Ellyn, Wheaton, Addison, Bartlett, Glendale Heights, Schaumburg, Itasca, Wood Dale and all surrounding areas.
Technology

The Lastest technology is essential in providing you the best quality care possible. Associated Dental Care utilizes the most recent technology available.

Veneers

A beautiful way to correct stained, chipped, or uneven teeth

Cosmetic

Even the most subtle change in your smile can make a dramatic difference in the way you look and feel about yourself.

Invisalign

Associated Dental Care is an Invisalign Prefered Provider specializing in Invisalign.

Whitening

Everybody loves a bright white smile, and there are a variety of products and procedures available to help you improve the look of yours.

Implants

Implants are used to support individual crowns, bridges or to help retain removable dentures more securely.

Patient Information page

  • About You


    Patient Information

    Last Name *
    		 Middle Name
    I prefer to be called:  
    		 Birth date (MM/DD/YYYY) *
    		 Driver's Licence No
    		SS#
    - -
    Home Address *
    		 City *
    		 State *
    		 Zip *
    Phone Number Home Mobile Work Email
    * - -
     
      - -
    Person Responsible for charges
     
    Gender
    Marital Status
     
    Whom may we thank for referring you?




    Your Employer's Name
    		 Employer's address
    		 City
    		 State
    Occupation
    In the event of an emergency, whom should we contact ?
    Name *
    		 Email ID
    Phone Home Mobile Work
    * - -
     
      - -
     
    Spouse / Parent Information
           
    Last Name
    		 First Name
    		 Relationship to Patient
    		 Occupation
    Employer
    		 Employer's address
    		 Phone
    - -     		Driver's Licence No.
    Date of Birth (MM/DD/YYYY)
    		  
     
     

  • Insurance


    Insurance
    Primary Dental Insurance
     
    Insurance Co. Name *
    		 Insurance Co. address
    Insurance Co. Phone #: *
    - -     		Group, Plan, Local or Policy no. *
    Insured's Name *
    		 Relation
    SS#
    - -     		Insured ID *
    Birth date (MM/DD/YYYY) *
    		 Insured Employer *
    Secondary Dental Insurance
    Insurance Co. Name
    		 Insurance Co. address
    Insurance Co. Phone #:
    - -     		Group, Plan, Local or Policy no.
    Insured's Name
    		 Relation
    SS#
    - -     		Insured ID
    Birth date (MM/DD/YYYY)
       

  • Dental Information


    Smile Appraisal
     
    Please take a moment to tell us how you feel about your smile.
    Do you feel like it reflects the right image of you?
    What would you change about your smile to make it reflect your image?
     
    Dental Information
     
    Purpose of your intial visit ? *
    		 When was your last dental visit? *
    Do you visit the dentist regularly ? How often do you visit the dentist?
    How often do you brush your teeth?
    		 How often do you floss?
    Previous Dentist Name
    		 Address
    		 Phone
    - -
    Are you aware of any dental problem ? Yes
    Have you had or do you have any of the following ?
    Clench or Grind your teeth ?   Ear Pain
    Jaw Clicking or Popping Gums hurt / bleed
    Pain of jaw muscles Sores or lumps
    Sensitive teeth    
     
     

  • Health History


    Full Name :
       
    What do you consider your general health to be?
    Health History * All fields are required
    Have you EVER been diagnosed with or experienced any of the following?
    Anemia   Kidney Disease
    Angina/Chest Pain Liver Disease
    Asthma Lungs Disease
    Bleeding Tendency Lupus
    Cancer Mental Illness
    Chemotherapy Mitral Valve Prolapse
    Depression/ Anxiety Osteoporosis
    Diabetes Prostheses/ Implant
    Drug/ Alchohal Addict Radiation Treatment
    Epilepsy Rheumatic Fever
    Hay Feaver Sinus Problems
    Heart Disease Stroke
    Heart Murmur Tuberculosis
    Hepatitis Ulcers
    Hypertension Recent Illness
    HIV Others
     
     
     
     
  • General Health * All fields are required
     
    Are you currently under the care of a physician?
    Have you ever responded unfavorably to Dental/Medical care?
    Do you get short of breath after a little exertion?  
    Have you been hospitalized in the last 5 years ?
    Do you smoke?
    Do you chew tobacco?
    Is there a possibility that you are pregnant?
    (Please make us aware if you ever become pregnant)    		  
    What was your last known blood pressure? /
    Allergies * All fields are required
       
    Please Select if you have had an allergic reaction to any of the following : If Yes, Explain Reaction
    Penicillin
    Novocain
    Aspirin
    Latex
    Codeine
    Barbiturates
    Sulfa
    Mycin Family
    Cipro
    Other Allergies:
    Medications
     
    Do you need to premedicate for dental visits?
    Are you taking any medications at this time?
    		 
    Have you EVER taken any of the following drugs?
     
     
       
     
    When did you take these drugs? 0-1yr 1yr-3yr 3yr-6yr 6yr-10yr 10yr +
     
     
  • Primary Care Physician Information
     
    Physician's Name
    		 Phone No
    - -     		Last Visit Date (MM/DD/YYYY)
    Any other health concerns?
     
    Thank You
    Thank you for taking the time to provide us with this important information. Please sign below to indicate that the information on this form is correct to the best of your knowledge and that you understand that it is your responsibility to inform us of any changes.
     
    Full Name
    Date(MM/DD/YYYY)
     
     
Associated Dental Care, 183 S. Bloomingdale Rd. Suite 202, Bloomingdale, IL 60108

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