Request an Appointment

Use the form below to send an appointment request to our office or call us in Rockford, IL – 815-397-2752, Margengo, IL – 815-568-7822 or Winnebago, IL – 815-335-3070. Our hours are 8:00 am to 5:00 pm, Monday – Friday. We will contact you as soon as possible, during our hours of business, to verify your appointment.

Patient Name*
First Last
Parent or Guardian Name
If patient is under 18 years of age.
First Last
Email*
Daytime Phone*
Alternative Phone
Preferred Day*
Day and time will be confirmed once we contact you.
MM slash DD slash YYYY
Preferred Time
Day and time will be confirmed once we contact you.

: Hours

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Tell us about your dental needs*
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