Request Appointment

To request an appointment, please fill out the form below. Our representative
will get in touch with you to confirm your appointment.

  • First Name:
  • Middle Name:
  • Last Name:
  • Address:
  • City:
  • State:
  • Zip code:
  • E-mail Address:
  • Phone Number:
  • Secondary Phone Number:
  • Best Time to Contact You:
  • Health Insurance Plan:
  • Birth Date:
  • Diagnosis / Symptoms:
  • Additional Information:
Reset     Submit

Your Visit

In order for us to make your visit as comfortable as possible, please bring the following items with you at the time of your visit:

Billinig and Insurance

We accept all major insurance plans and the list of managed care networks to which we belong is constantly growing. We also accept credit cards and offer payment plans.

Some insurance plans require referrals, or may have additional requirements for the specific services. Please contact our billing office or call your insurance carrier if you have any questions about your insurance coverage.

Phone Scheduling

You can also request appointment by phone: (773) 772-7575.

Western Diversey Surgical Center | 2744 North Western Avenue, Chicago, IL 60647 | Ph: (773) 772-7575 | Privacy Policy