Appointment Request Form Preferred Location*MerrillvilleHammondCrown PointGaryGriffithHebronLowellGlen ParkWinfieldSt. JohnFirst Name* Last Name* Patient Type*New PatientCurrent PatientReturning PatientAddress* Date of Birth* MM slash DD slash YYYY Email* Phone*Appointment Date* MM slash DD slash YYYY Appointment Time*Morning AppointmentAfternoon AppointmentEvening AppointmentQuestions & CommentsUntitledFirst ChoiceSecond ChoiceThird ChoiceNameThis field is for validation purposes and should be left unchanged.