630-912-2700Request an appointment

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Before your first visit

New patient intake

Filling this in beforehand means we can prepare, and it saves you a clipboard in the waiting room. Nothing here commits you to treatment.

Rather do it another way?

Call us on 630-912-2700 and we will take these details over the phone, or arrive a few minutes early and do it here.

Please keep clinical detail brief here — anything sensitive is better discussed at the appointment itself.

About you
How should we contact you?
What would you like to sort out?

Tick anything that applies. Nothing here commits you to treatment.

If you ticked something that needs detail — which tooth, how long, what changed — this is the place.

Sign and send

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or the patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Your typed name is your signature. We record it with the date and time.

We will call or email — whichever you chose — to arrange your visit. Nothing here is a commitment to treatment.