Accessible Version
Children's Center for Dentistry
GREGORY DIETZ DMD

New Patient Forms

Save time waiting in our office by filling out necessary forms at home. Feel free to give us a call if you have any questions.

 

New Patient Child Forms

New Patient Infant Forms

COVID-19 Screening Questionnaire

Have Questions? Get in Touch
If you have difficulty using our website, please email us or call us at (309) 827-5437
View the ADA Accessibility Statement

At Children’s Center for Dentistry, the health and wellness of our patients, staff, and doctors is our top priority. We have developed a re-opening plan, starting May 13, 2020, that is approved within the Governor’s shelter-in-place order that extends through the end of May. Our plan will expand our care back open to essential and preventative services.

CLICK HERE to learn more.