Request an Appointment

Ready for an Appointment? Give us a call or use the form below.

Please use the form below, or call (847)991-0480 to schedule your appointment.

First*
Last*
Phone
Email
Appointment Type*
- Current Patient
- New Patient
Preferred Contact*
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- Phone
Insurance*
How did you hear about us?*
Other*
Other Referral*
Please Choose at least one Date/Time that works for your schedule.
Date*
Date Format: MM slash DD slash YYYY
Time*

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MM
Second Choice (optional)
Date Format: MM slash DD slash YYYY
Time

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MM
Third Choice (optional)
Date Format: MM slash DD slash YYYY
Time

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Hours
Mon.	9am – 5pm
Tue.	10am – 6pm
Thur.	9am – 5pm
Fri.	8am – 3pm

Haupers Family Dental