Welcome to CASG

Are you 18 years old or older?

YesNo
Unfortunately,

In order for us to proceed with your appointment scheduling request, you must be 18 years of age or older. Please contact a parent or guardian to complete this form. Thank you.

Sincerely,

Oral-B & Kare Mobile
Choose screening location?
Choose screening date? [Elgin, IL]
Is the patient under 18?

YesNo
Parent or Legal Guardian Info
Relationship to patient(s) ?
Parent or Guardian Name*

First NameLast Name
Parent/Guardian Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Information
Patient Full Name

First NameLast Name
Patient Email
example@example.com
Patient D.O.B.

MonthDayYear
Date
Patient Gender
Patient Medical history, please check all that apply

Anemia, Sickle Cell DiseaseMuscle, Bone, Joint ProblemsAsthma or Breathing ProblemsBrain or Nervous System ProblemsCancer, Cancer TreatmentDiabetesHeart ProblemsHigh Blood PressureKidney DisordersStomach or Intestinal ProblemsNone of the aboveOther
Does have any drug allergies ?

NoYes
Please provide Patient drug allergies
Is Patient currently taking any medications ?

NoYes
Please list any current medications for Patient
Dental History
Is Patient currently experiencing any pain ?
Patient | Dental History, Please check all that apply

CavitiesMouth SoresBleeding GumsDry MouthBroken TeethTeeth GrindingTooth AcheSensitive TeethJaw Joint PainTeeth WhiteningNone of the above
How often does Patient brush their teeth daily ?
Which toothpaste does Patient use most ?
How often does Patient visit a dental office ?
FINAL BREAK POINT
Insurance Info
Do you have dental insurance ?
Choose your insurance provider
Please enter your insurance provider
Other Insurance Provider Name
Nearby Dental Offices

These nearby dental offices accept Medicaid
Mahairi Dental Center
15 N Geneva St, Elgin, IL 60120
847-488-1909

Smiles on Randall
2158 N Randall Rd, Carpentersville, IL 60110
847-426-9430
Product Recommendations

Please see your personalized list of recommend products
iO Exceptional Clean
Crest Gum Detoxify
Crest 3D White Ultra
Fixodent Original Advanced Max Hold
Crest ProHealth Advanced White Toothpaste
Crest Densify Daily Whitening
Crest 3D White Professional Whitening
Crest Complete Outlast Ultra Toothpaste with Scope
Crest 3D White Glam Rinse
Crest PH Advantage Rinse
Oral B Glide Floss w/Brillance Blast
Oral B ProAdvantage Battery Brush Black & White Handle
Oral B ProAdvantage Deep Clean + Whitening Toothbrush 8pk
Crest Whitestrips Professional Effects & Supreme Bright Dual Pack
Crest Whitening Emulsions
Oral B Pro Clean X Electric Toothbrush
Confirm today's date

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Date
Terms & Conditions
Signature*

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Parent or Legal Guardian Info

Patient Information

Dental History

FINAL BREAK POINT

Insurance Info

Nearby Dental Offices

Product Recommendations

iO Exceptional Clean

Crest Gum Detoxify

Crest 3D White Ultra

Fixodent Original Advanced Max Hold

Crest ProHealth Advanced White Toothpaste

Crest Densify Daily Whitening

Crest 3D White Professional Whitening

Crest Complete Outlast Ultra Toothpaste with Scope

Crest 3D White Glam Rinse

Crest PH Advantage Rinse

Oral B Glide Floss w/Brillance Blast

Oral B ProAdvantage Battery Brush Black & White Handle

Oral B ProAdvantage Deep Clean + Whitening Toothbrush 8pk

Crest Whitestrips Professional Effects & Supreme Bright Dual Pack

Crest Whitening Emulsions

Oral B Pro Clean X Electric Toothbrush

Terms & Conditions