Patient Forms

For your convenience, please feel free to print out and fill in the new patient information below.


NOTICE: There will be a $30 fee for appointment cancellations within 24 hours of your scheduled visit, and/or a no-call, no-show appointment.


Appointment request
Need an appointment with a dentist in Peoria ? Requesting an appointment at our Peoria, 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
Describe the nature of your appointment or any other comments