Appointment Request Form for New Retainers

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Three simple steps to order your new retainers:

1. Fill out this appointment request form and wait for AllCare customer service associate's call to set up an appointment;

2. Come for your appointment and have new records (i.e., 3D iTero intra-oral scanning) taken by AllCare's imaging specialists;

3. Pick up your new retainers in 7-10 business day.

AllCare Orthodontic Center location 842 W. 31st Street, Chicago, IL 60608 (Free parking)

If you have any questions, please contact us at 312-804-8304 or email allcareortho@gmail.com.

Email *

Are you a new or existing patient at AllCare Orthodontic Center?

I am a new patient.

I am an existing patient who finished my orthodontic treatment at AllCare in the past.

Clear selection

When did you finish your previous orthodontic treatment? *

within a year.

2-3 years ago

4 or more years ago

What is the reason you would like to order new retainers? *

Please check all answers applied

I lost my previous retainers.

My current retainers got worn out (e.g., cracks, holes, scratches or stains on the retainers).

My current retainers don't fit my teeth (e.g., too tight, too lose).

My current retainers cause discomfort when I wear them.

I had dental work (e.g., new crowns, fillings, implants) done recently by my dentist. I need to order new retainers that fit.

I need an extra pair of retainers as back up.

Other:

Required

What time during the week works the best for you?

Monday afternoon

Tuesday morning

Tuesday afternoon

Wednesday morning

Wednesday afternoon

Friday morning

Friday afternoon

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How did you hear about AllCare Orthodontic Center?

My dentist/oral hygienist

A friend or family member

Social media

Google search

Insurance company provider listing

Other:

How did you hear about AllCare Orthodontic Center?

My dentist/oral hygienist

A friend or family member

Social media

Google search

Insurance company provider listing

Other:

Contact information

Please fill out your contact information. AllCare customer service associates will contact you soon. We speak English, Mandarin, Cantonese and Spanish.

Your name *

Phone number *

E-mail *

Preferred contact method *

Phone

Required

Questions and comments

A copy of your responses will be emailed to the address you provided.

Submit

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