Appointment Request

   Thank you for your inquiry into our office. The first step towards a beautiful, healthy smile is to schedule an appointment. 
    Dr Vakili is in high demand in the Peoria area. We currently have a new patient waiting list and are scheduling new patient exams as he has availability.
    To be placed on the scheduling call list please complete our new patient registration by following the link below. 
    Dr. Vakili will review your request and we will call you to schedule your comprehensive new patient evaluation.

Please do not use this form to cancel or change an existing appointment.
*Items in bold are required.
Are you a current patient?

Preferred day(s) of the week for an appointment?

Preferred time(s) for an appointment?

Please describe the nature of your appointment (e.g., consultation, check-up, etc.):

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.