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* Reason for appointment:
Please tell us a little about the condition causing you to request an appointment.
We want to provide you with the very best care that meets your unique needs. Because of the complex nature of neurological conditions, our schedulers will work with you to schedule an appointment with the physician most suited to your needs. Sometimes, this may not be the physician you are requesting an appointment with.
Please check if you are physician or a physician's representative and want to submit additional information with this request.
In order to provide the best care for your patient, please fax the patient's medical records to Peoria - (877) 464-6806 or Rockford (815) 387-1718. Thank you.