To request an appointment, submit the form below, and we will contact you to confirm a date and time. If your matter is urgent, however, please call us at 773-649-5200 and DO NOT use the form.


Your Name*

Your Email*

Your Phone Number*

Request Appointment Date*

Preferred Time of Day?

Reason for Appointment*

Do you have dental/orthodontic insurance coverage?*

(*If answer is yes, please remember to bring your insurance card with you to your appointment)