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Patient Portal Make a Payment

Appointment Request Form

Welcome! We’re so glad you’ve chosen to start your smile journey with us at Kozak Orthodontics. Dr. Kozak and the staff can’t wait to meet you and help you achieve the smile you’ve always wanted.

To get started, please answer the following questions to request a first appointment with us!

Patient Information

Patient Name(Required)

First Last

Patient Date of Birth(Required)

Responsible Party Information

Self choice

Appointment for Self

Guardian Name(Required)

First Last

Contact Information

Phone(Required)

Email(Required)

Preferred Location

Antioch Office

Kenosha Office

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