Gentle dentistry practice

Dr. Donald Witter, D.D.S 9500 Pennsylvania Avenue, #14 Melwood Professional Center Upper Marlboro, Maryland 20772 301-599-1670 Fax: 301-XXX-XXX Specializes in the below procedure(s): Crowns; Bridges; Preventive Dentistry; Fillings; Bondings. Extractions; Root Canals; Teeth Whitening; and Dentures. New patients welcome - Apointments available (Mon: 1:00 p.m. to 5:00 p.m.) (Tues - Friday: 9:00 a.m. to 5:00 p.m.) Please CLICK on the below button to PRINT this form. Fill it out, then FAX it or attach it to the Email you are sending. Homepage| About Us| Print Form| |Schedule online

Patient Information: Name:______________________________________________________________________________________ Street Address:_____________________________________________________________________________ City: ______________________________________ State: ________________Zip:______________________ Phone: ______________________________________ Fax:__________________________________________ Email:______________________________________________________________________________________ Desired Evaluation(s): Evaluation No. Description of Problem                                         Member of United Accordia Companies, Incorporated