Request an Appointment

Windy City Smiles

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Patient Information

Type of Patient

New Patient

Established Patient

First Name

Last Name

Home Phone Number

Cell Phone Number

Email Address

Date of Birth

Insurance Information

Name of insurance company

Policy/plan number

Name of policy holder

Policy holders date of birth

Policy holders social security number

Reason for Appointment

Date of last dental visit

Date of last dental cleaning

Date of last dental x-rays

Do you smoke or chew tobacco?

Please check any of the following problems that might apply to you

Tooth pain or discomfort while chewing

Loose, tipped, or shifting teeth

Grinding or clenching teeth

Bleeding teeth or fillings

Broken teeth or fillings

Headaches, earaches, or neck pain

Jaw joint pain

Sensitivity (hot, cold and/or sweet)

Routine appointment

Your Smile

If you could change your smile you would...

Make your teeth brighter

Make your teeth straighter

Close spaces

Replace black metal fillings with natural, tooth colored fillings

Repair chipped teeth

Replace missing teeth

Have a smile makeover

Replace old crowns that don't match

Other

Thank you for your request.
Please allow us two business days for a response.

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Windy City Smiles

773-588-SMILE
www.WindyCitySmiles.com
3521 N. Elston Ave

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