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

We would like to limit the spread of COVID-19 in our community by asking patients to call and reschedule if you have any COVID-19 symptoms, if you have been in contact with anyone with COVID-19, or you have traveled to a COVID-19 hot spot or out of state within the past two weeks. In addition, we are limiting only one parent/guardian to accompany our patients unless otherwise agreed upon. All persons that enter our building are to wear masks and are asked to keep a minimum social distance of 6 feet.