New Patient Special Promotion - Glen Ellyn, IL

New Patient Promotion

dental patient filling out form

New Patient Special Promotion

To redeem your new patient offer of $99 for exam, x-rays and *cleaning, please fill out this form and our treatment coordinator will call you to schedule your appointment.

*New patients only. Cannot be used in conjunction with insurance or other offers. Does not include periodontal services. Not redeemable for cash.

I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act.

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