Dreyer Medical Clinic - Request an Appointment Step 2

Serving the Fox Valley Since 1922

Patient Information

Your Name: (If different from Patient's name)
Patient's First Name:
Patient's Last Name:
Patient's Date of Birth:
Patient's Home Address:

City:
State:	Illinois
Zip Code:
Day Time Phone Number:
Email Address:
Gender:
Medical Record Number: (if known)

Select a Speciality & Doctor

* Remember, the online request can only be used for primary care physicians (Internal Medicine, Family Practice and Pediatrics), and a few specialists (Allergy, Nephrology, and Rheumatology). Appointments with all other specialists must be made by phone or in person. Dreyer can suggest some physicians for you to choose from if you are a new patient.
Select a Specialty	Select a Physician
	After selecting a specialty, a list of doctors will appear in the field above.

Select Your Appointment Preferences

Location Preference
Day of the week:
Time of day:
Best time to contact you:

Tell Us the Nature of Your Appointment

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