New Patient Form

Print out and complete a new patient information form and HIPAA form before your first appointment.

Then just bring them with you to save time!

 

New Patient Form

Appointment request
Need an appointment with a dentist in Fairview Heights ? Requesting an appointment at our Fairview Heights, IL family and cosmetic dental office is now easier than ever. Fill out the form below and we'll contact you to find a time that fits your schedule. Start your journey towards a beautiful smile with us today!
Patient Name*
Phone Number*
Email Address
Are you a current patient?
Best time(s) to call?
Preferred Appt Date
Preferred Appt Time
Message
Describe the nature of your appointment or any other comments