Pay Your Bill
You may pre-register with our office by filling out our secure HIPAA compliant online Patient Registration Form. After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.
Online Patient Registration Form
Print our PDF version, fill it out and bring to your appointment.
PDF Patient Registration Form
Contact us with any questions or to schedule an appointment to reclaim your smile today!
Serving Central Illinois:Bloomington IL • Normal IL • Twin Grove IL • Hendrix IL • Covell ILBentown IL • Shamrock IL • Towanda IL • Shirley IL • Danvers ILCarlock IL • Merna IL • Randolph IL