Dr. Donald Witter, D.D.S
9500 Pennsylvania Avenue, #14
Melwood Professional Center
Upper Marlboro, Maryland 20772

301-599-1670
Fax: 301-XXX-XXX

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SCHEDULE APPOINTMENTS ON LINE

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Active Patient
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First Name: *
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Home Phone: *
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Referral Source:
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PURPOSE OF DENTAL VISIT
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Bleaching/whitening Bonding
Braces Broken or missing teeth
Cleaning & check-up Cosmetic dentistry
Crowns, caps & fixed bridges Dentures
Diagnosis of soft tissue lesions Emergency
Examination Extraction
Fillings FREE initial consultation for new
     patients
Implants Oral Microbiology
Oral Surgery Pain
Periodontal (gum) therapy
     or surgery		 Porcelain laminates/veneers
Post and core Reevaluation
Retainers (fixed or removable) Root canal therapy
Root planning & scaling
    (deep cleaning)		 Sculpting (reshaping teeth)
Temporary filling or caps TMJ & bite plates
Wisdom teeth X-rays

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PREFERRED DAYS AND TIMES OF APPOINTMENTS
Office hours: Monday: 1:00 p.m. 5:00 p.m. and Tuesday - Friday, 9:00 a.m. - 5:00 p.m.
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Preferred Time of Day (hh:mm a.m.or p.m.): *
Preferred Days (Tue/Wed/Thu/Fri): *
Preferred Dates (mm/dd): *
Preferred Provider (if any):
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APPOINTMENT CONFIRMATION
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Home Phone      Office Phone      Email
If you send this "Schedule Appointments Online" form to us Tuesday - Friday between 9:00 a.m. and 5:00 p.m., or after business hours, you will receive your confirmation by the end of the next business day.
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Homepage| About Us| Print Form|
|Schedule online

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