Appointment Request
Please complete the online form below to request an appointment. We look forward to seeing you!
*
Office Location:
Select A Location
Alton, IL - 3432 College Avenue
Belleville, IL - 1801 North Belt West Suite C
Belleville, IL - 5300 West Main
Bloomington, IL - 507 North Hershey Dr., Suite D
Bloomington, IL - 1507 N. Veterans Parkway
Champaign, IL - 14 East Anthony Dr., Suite B
Columbia, IL - 242 Southwoods Centre Drive
East Alton, IL - 50 North Center Street
Gahanna, OH - 690 Morrison Road, Suite B
Litchfield, IL - 515 North Monroe
Peoria, IL - 3412 W. Willow Knolls Rd., Suite A
Rockford, IL - 5819-21 E Riverside Blvd.
Springfield, IL - 2965 S. MacArthur Suite B
St. Charles, MO - 1600 Heritage Landing, Suite 210
St. Charles, IL - 615 South Randall Road, Unit 110
Tampa, FL - 5200 N. Armenia Ave.
*
First Name:
*
Last Name:
*
Phone #
(With Area Code)
:
*
E-Mail Address:
Are you a new patient?
YES
NO
Preferred day of the week?
MON
TUE
WED
THU
FRI
ANY
Preferred time of day?
A.M.
P.M.
How did you find us?
Word of Mouth
Print Ad
Radio Ad
Direct Mail Ad
Yellow Pages
Web Search
Other
*
Required Fields
Please print and fill out the new patient form below and return it to our office at the time of your appointment.
Download Form
Home
|
Office Locations
|
Appointments
|
Member Benefits
|
Contact Us
|
Privacy
Affordable Dentistry Today, PC, Scott Ritchhart, DMD, O. Craig Shanteau, DDS, Samson Liu, DDS, Owners
