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217-359-8697
14 East Anthony Drive Suite A, Champaign, IL 61820
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General Dentistry
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Extractions
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Night Guards
Oral Cancer Screening
Periodontal / Gum Disease Treatment
Sealants
Sleep Apnea
Smoking Cessation
TMJ, TMJD and TMD Treatment
The KaVo DIAGNOdent Laser Cavity Finder
Wisdom Tooth Extraction
Cosmetic Dentistry
Dental Crowns
Invisalign
Lumineers
Traditional Braces
White Fillings
Zoom! Teeth Whitening
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Dental Implants
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Root Canal Therapy
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Nitrous Oxide Comfort Dentistry
Oral Medication Comfort Dentistry
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Home
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Patient Resources
Make an Appointment
Solutions & Services
General Dentistry
Cold Sore Treatment
Comprehensive Exams
Digital X-Ray
Emergency Dental Care
Extractions
Gentle, Professional Cleanings
Mouth Guards
Night Guards
Oral Cancer Screening
Periodontal / Gum Disease Treatment
Sealants
Sleep Apnea
Smoking Cessation
TMJ, TMJD and TMD Treatment
The KaVo DIAGNOdent Laser Cavity Finder
Wisdom Tooth Extraction
Cosmetic Dentistry
Dental Crowns
Invisalign
Lumineers
Traditional Braces
White Fillings
Zoom! Teeth Whitening
Restorative Dentistry
Dental Implants
Dentures
Root Canal Therapy
Comfort Dentistry
Nitrous Oxide Comfort Dentistry
Oral Medication Comfort Dentistry
Make an Appointment
First Name
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Last Name
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Phone Number
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Email Address
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Verify Email Address
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Date of Birth
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Date
E.g., 08/21/2017
Are you a new patient?
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Yes
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How did you hear of us?
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Patient Referral
Website/GoogleSearch/Etc.
1800 Dentist (per referral)
Location/Drive By/Sign
Daily Deal/Groupon
Insurance Company
Yellow Pages Print
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Is your family, friend or coworker a current patient? We’d love to have their name so we can thank them for referring you to us
How did you hear about our office?
Reason for your visit
*
Dental Cleaning
Dental Emergency
Dentures or Implants
Cosmetic - teeth whitening, veneers, bonding, etc.
Filling
Crown
Extraction
Dental Consultation (Second opinion or Invisalign)
Other
Please provide a brief explanation of the reason for your visit
Are you experiencing pain, swelling, or bleeding?
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Where is the problem area located?
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Rate pain (1-10)
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10
On a scale of 1 to 10, please rate your level of pain with 1 being the least and 10 being the most.
Do you have insurance?
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Who is your dental insurance provider
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Monday
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Best time?
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Specific Time
If a specific time is necessary, please indicate the time.
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Note: we do not accept appointment cancellations via email.
Do you require any special accommodations?
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Accommodations required
In order to request an appointment you must be 13 years of age or older.
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Yes, I am 13 years of age or older
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Office Hours
Monday:
8:00 AM - 5:00 PM
Tuesday:
9:00 AM - 5:00 PM
Wednesday:
8:00 AM - 5:00 PM
Thursday:
8:00 AM - 5:00 PM
Friday:
8:00 AM - 4:00 PM
