new changes for illinois residents please see information page

When you submit this form, a staff person will call within 24 business hours to verify information and set the final appointment.

If you are trying to reach the clinic by phone after our normal business hours please call 618-346-3040.

Request an Appointment

Today's Date
Today's Date
Name *
Phone *
Please give us a number where you may be safely reached. Any further instructions can be placed in the comment line below.
Private Care
If you want to be in private waiting and recovery areas, check here. (Extra charge $125)
Appointment Day/Time *
Requested Date of Appointment *
Requested Date of Appointment
Please do not give us any medical information on this form.