Schedule An Appointment

Making an appointment with our Pediatric Dentists, Dr. Orbon, Dr. Maddox and Dr. Wagner at Affiliated Dental Specialists is easy.

1.	Complete this form online and click SEND. We will contact you shortly.
2.	Or contact us by phone for an appointment during business hours.
3.	Or print this form, complete it and fax it to one of our office locations: Vernon Hills Fax: 847-367-6079 Gurnee Fax: 847-263-1890

First name:
Last name:
Email address:
Phone number:
Home address:
City:	State:	Zipcode:
What time of the day and day of the week works best for you? Morning (7 am - Noon) Afternoon (1:30 pm - 5:00 pm) Mon Tues Wed Thurs Fri Sat No preference
In general, what dental services do you need?
What specific types of dental services do you want? Include as much detail as you wish.
Select the appropriate department you'd like this message directed to:
How did you hear about us?
Antispam:*
Enter Code:* (not case sensitive)