MAKE AN APPOINTMENT WITH DR. FONTANA
Fill out the form below and click on the submit button.
You will be contacted by phone or email on the next business day to schedule your appointment date and time.
If you have an EMERGENCY DO NOT USE THIS FORM. Please call 313-881-8080.
Name:
Address:
Phone:
Email:
Reason for visit:
Recent X-Rays?

Yes No         Date

Current Patient?:
YES NEW  
Age :
 
Insurance?:
YES NO
If Yes, Insurance Provider:
Date Requested:
Time Requested:
 
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