Patient Forms - Family Gurnee, IL Dentist - Dr Tom Bezouska

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847-623-4888

3930 Washington
Street,Ste. A Gurnee,
IL 60031

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Patient Forms

You can save time by printing out these froms and filling them in for your first visit - thank you! We look forward to getting to know you and helping you create the smile you've always dreamed of.

Thank you!

1.  Patient Health

Patient Health Form

2.  Dental History

Dental History Form

3.  Financial Policy

Financial Policy Form

4.  Missed Appointments Policy

Missed Appointments Policy

5.  Post Op Crowns & Bridges

Post Op Forms - Crowns & Bridges

6.  Post-Op Endodontics

Post Op Endodontics

7.  Post Op Extractions

Post-Op Extractions

8.  Post Op Implants

Post Op Implants

Our Special Offers

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FREE Teeth Whitening! With exam, cleaning & x-rays Exp. 5/31/2012

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$1 New Patient Exam! Initial exam, x-rays, consultation Exp. 5/31/2012

Office Hours

Monday7:00AM-6:00PM
Tuesday7:00AM-6:00PM
Thursday7:00AM-6:00PM
Friday7:00AM-6:00PM
Saturday7:00AM-2:00PM

Testimonials


Dr. B,  I want to thank you for giving me the beautiful teeth that I always wanted.  Thanks to all the wonderful girls y....
Marcella S.

Dr. Bezouska had been telling me for years to get a bruxism guard to prevent damage to my teeth and jaw from grinding my teeth at ....
Brandon

Dr. Bezouska,I just wanted to let you know how pleased I am with my new dentures. They have been comfortable and natural looking f....
Kathy

Fantastic! Dr. Bezouska is a very excellent dentist. Always going to seminars to learn new procedures. He's great at working with ....
Heidi

I appreciate the whole process that Dr. Bezouska takes you through. I really came to the right place. Walter....
Walter

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