Mobile Dentistry In Your Home

Brian Homann DDS

847-558-1222

Thank you for your interest in receiving mobile dental care from Dr. Brian Homann. PLEASE READ THIS FORM VERY CAREFULLY. This form will explain the expectations and limitations of the care being provided.

Mobile Dentist

Who can receive treatment ?

This mobile dental unit is designed for people who do not have the ability to be seen at a traditional dental office. This may be due to many factors, including illness, disability, or lack of transportation.

How is treatment provided ?:

Dr. Homann will travel to your residence with a mobile dentistry set up. He will require a normal wall outlet to plug in his equipment. He will also require space to set up a mobile dental chair and unit. An 8 foot by 8 foot area is ideal. If you have any questions about available space, please call to discuss prior to setting up an appointment.

What treatment is provided ?:

Due to the mobile nature of the service, the scope of service is more limited than at a traditional dental office. Services include, but are not limited to: Exams, preventative care (cleanings, sealants, fluoride), radiographs (x-rays), fillings, deep cleanings, extractions, and denture services. If a patient requires treatment that cannot be completed in the home, a referral may be given to an appropriate dental specialist or physician.

What needs to be done prior to the first visit ?:

The entire new patient packet must be completed and sent to Dr. Homann’s office. He will review the medical history and call you if he has any questions. Please be sure to provide all physician names and contact information when filling out the medical history. This helps to prevent potential situations where dental work could not be started without Dr. Homann first having a discussion with your physician about a specific, complex medical issue.

What does the first visit involve ?:

At the first visit, Dr. Homann will review your medical history, complete a full exam, take any necessary radiographs (x-rays), have a discussion about your oral health condition, and make a plan for any necessary treatment. If time allows, treatment may be started at the initial visit. If the patient is not able to make decisions for him/herself, the guardian or medical power of attorney must be present at the initial visit.

How does payment work ?:

Payment is due at the time of service. Payment can be made via check, cash, credit card, or Care Credit. If you have dental insurance, we will be happy to file your claim for you. Any reimbursement will be sent directly to you.

Cancellation Policy :

When an appointment is made, time is set aside specifically for you. For that reason, we require a minimum of 48 hours notice prior to your appointment for any cancellation or rescheduling. There is a fee of $150 for any cancellation or rescheduling less than 48 hours prior to an appointment. If there is a true medical emergency, please contact us. If a note from a physician is provided stating that the patient is unable to be seen due to medical reasons, the fee will be waived.

By signing below, I certify that I have read and understood the above policy.



Patient’s or Legal Guardian’s/Representative’s Signature Date
Legal Guardian or Medical Power of Attorney

If the person authorized to make medical and dental decisions about treatment is not the patient, documentation needs to be provided.

If the person (patient) receiving care is the person in charge of their care, please do NOT fill out this form.

If the person (patient) receiving care is not the person in charge of their care, please fill out the form below and provide a copy of necessary documentation.