Make an Appointment

Download and print Patient forms before your scheduled appointment. Forms are available in PDF format.

 

Making an appointment with Tooth Fixer Dental is easy.

Option 1: Complete this form online and click SEND.
Option 2: Print the form, complete it and fax it to us at (630) 585-5656 and we will contact you.
Option 3: Call us for an appointment at (630) 585-5600 during business hours.

If you are unable to keep an appointment,
we ask that you provide us with at least 48 hours advanced notice. 
* Required 
First name *  
Middle initial  
Last name *  
Street address  
Apartment #  
City  
State / Province  
Zip / postal code  
     
Phone Number *  
Cell Phone  
Email address *  
What time of the day and day of the week works best for you?   Daytime (8am - 5pm) Evening (5pm - 7pm)

Mon Tue Wed Thu Sat
     
What types of dental services do you need?  
     
Do you have a specific dental concern?  
How did you hear about us?  
Friend / Relative Internet Search Outside Sign
Phone Book Postcard Other
Insurance Company