Schedule your visit Request an Appointment Services (773) 777-4767 Please note: This form is for general registration purposes.We will contact you by phone to schedule the exact date and time of your appointment. Filll in the form Insurance Plan Please select Paying out of pocket (Self-pay) I will provide my insurance later Aetna Blue Cross Blue Shield (BCBS) Cigna Medicaid / All Kids (Illinois) UnitedHealthcare Other Reason for your visit Please select Routine Well-Child Exam Sick Child Visit (Fever, Earache, Cough) School or Youth Sports Physical Behavioral or Learning Evaluation Newborn Hospital Follow-up Prenatal Consultation (Expecting Mothers) Immunizations / Flu Shot Has the patient seen Dr. Banas before? Please select Yes, we are a current patient No, we are a new patient Choose the type of appointment Please select In-office visit (6033 Irving Park Rd) Telehealth / Video visit First name Last name Date of birth Sex assigned at birth Please select Male Female Preferred Language for Visit Please select English Polish Russian Spanish Email Phone Number Additional Notes / Message for the Doctor I accept the Terms of Service and Privacy Policy. Book an Appointment
