Referring Doctors

If you are a dental care provider looking to refer your patient to us at Prime Dental Specialists, be sure to fill out their information below. Our prosthodontist, anesthesiologist and team will take care of them and provide them with the specialty dental care they need in Glenview, Illinois. For any questions, call 847-748-0061 to speak to Dr. Samantha Chou or Dr. Devin Roberts.

Referring Doctor:
Date:
 
Patient Name: First
Patient Name: Last
 
Date of Birth:
Sex:
Patient/Guardian:
Contact Telephone Number:
Reason for Referral:
Consultation regarding:
Tooth Chart:
(Please mark teeth for extraction/implant)
1

1
2

2
1

3
1

4
1

5
1

6
1

7
1

8
1

9
1

10
1

11
1

12
1

13
1

14
1

15
1

16
32

32
31

31
30

30
29

29
28

28
27

27
26

26
25

25
24

24
23

23
22

22
21

21
20

20
19

19
18

18
17

17
 
Radiographs
To diagnose and treatment plan patients thoroughly, a full mouth (FMX) set of radiographs are required.
Digital Radiograph attached*(JPG, No Bitewings)
Please take Pano or CT Scan
*Click the "Choose File" button below to attach your files.
All Fields Marked with '*' must be completed to submit the form
Your request has been sent -- we will be in contact with you shortly.
There was an error! Please phone our office.

Gleaming Reviews

Real Patient Experiences

Dr Samantha Chou in Glenview Illinois

I have had implants done last year. Dr Chou and her staff are just the greatest. My teeth look great and it is so nice to be able to eat anything that I want.

– Phyllis B

Dr Samantha Chou in Glenview Illinois

Dr. Chou and her staff made me feel very comfortable during my visit. I am pleased my suggested her,. I was not happy with my previous dentist.

– Rickey M

Dr Samantha Chou in Glenview Illinois

I have had extensive dental work done by Dr.Chou and her staff. They are kind, friendly and efficient. I recommend them.

– David I

Dr Samantha Chou in Glenview Illinois

Warm welcome to the new patients. Clear understanding of situations and genuine attention, trying to help. Thank you very much D-r. Chou!

– Chris C

Dr Samantha Chou in Glenview Illinois

Dr. Chou and her staff went above and beyond to insure that I was 100% satisfied with the work that was done. Their work was Excellent.

– Yvonne K

Dr Samantha Chou in Glenview Illinois

The staff was very friendly and professional! I was able to get my teeth taken care of in a timely manner! A very positive experience!

– Fiorella G