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217-398-9898
314 West Kirby Avenue, Champaign, IL 61820
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Zoom! Teeth Whitening
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Patient Resources
Make an Appointment
Solutions & Services
General Dentistry
Comprehensive Exams
Digital X-Ray
Emergency Dental Care
Extractions
Gentle, Professional Cleanings
Periodontal / Gum Disease Treatment
Root Canal Therapy
Cosmetic Dentistry
Dental Crowns
Invisalign
Lumineers
Smile Makeovers
Teeth Whitening
White Fillings
Zoom! Teeth Whitening
Restorative Dentistry
Dental Implants
Dentures
Make an Appointment
First Name
*
Last Name
*
Phone Number
*
Email Address
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Verify Email Address
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Date of Birth
*
Date
E.g., 04/26/2018
Are you a new patient?
*
Yes
No
How did you hear of us?
- SELECT Marketing Type -
Patient Referral
Website/GoogleSearch/Etc.
1800 Dentist (per referral)
Location/Drive By/Sign
Daily Deal/Groupon
Insurance Company
Yellow Pages Print
Other Marketing
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?
*
Yes
No
Where is the problem area located?
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Rate pain (1-10)
*
1
2
3
4
5
6
7
8
9
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?
*
Yes
No
Who is your dental insurance provider
Best day(s) for your appointment
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Monday
Tuesday
Wednesday
Thursday
Friday
Best time?
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Morning
Afternoon
No Preference
Specific Time
If a specific time is necessary, please indicate the time.
How do you prefer we contact you?
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Email
Phone
Note: we do not accept appointment cancellations via email.
Do you require any special accommodations?
*
Yes
No
Accommodations required
In order to request an appointment you must be 13 years of age or older.
*
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 - 5:00 PM
