Carol Chiu, D.D.S. - APPOINTMENT REQUEST

APPOINTMENT REQUEST

If this is an emergency, please don’t use this request form. Call this office directly or hospital immediately.

If you would like to schedule an appointment with us, please complete and submit the following form. As soon as we receive your request, we will contact you to schedule an appointment. If you don’t hear from us within 48-72 hours after sending out this request, please call this office directly. This request DOES NOT guarantee an appointment. We will call you to schedule a time for you to visit us.

First Name:
Last Name:
Street Address 1:
Street Address 2:
City, State, Zip:
Telephone:
E-mail:
Insurance Company:
Member ID Number:
Group Number:
Please call me to schedule an appointment for the following reasons:
	General Dentistry (checkup, cleanings, etc.) Gum Disease (Bleeding Gum) Cosmetic Dentistry (whitening, veneers, etc.) Teeth Restoration Others
Comments or Questions:
*If you have immediate concerns or problems or if you need to change your appointment, please call the office directly at 847-228-6118.*
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The Dentist

Dr. Chiu received her dental degree, in 1993, from Northwestern University Dental School with high academic and clinical honors.

The Office

Dr. Carol Chiu, D.D.S.
37 West Golf Road
Arlington Heights, IL 60005

Phone: (847)228-6118