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:
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2007
2008
2009
Time Requested:
9:00 am
9:15 am
9:30 am
9:45 am
10:00 am
10:15 am
10:30 am
10:45 am
11:00 am
11:15 am
11:30 am
11:45 am
1:00 pm
1:15 pm
1:30 pm
1:45 pm
2:00 pm
2:15 pm
2:30 pm
2:45 pm
3:00 pm
3:15 pm
3:30 pm
3:45 pm
4:00 pm
4:15 pm
4:30 pm
4:45 pm
Send a copy to me.
|
Home
|
Make an Appointment
|
Map/Hours
|
Contact Us
|
About DR
|
Photo Gallery
|
General Dentistry
|
Tooth Replacement Options
|
|
Tooth Whitening/All Ceramic Crowns/Veneers
|
Crowns and Full Mouth Reconstruction
|
Amalgam
|
Gold and Bonded (Composite) Restorations
|
|
Zoom®
|
Nite White®
|
Bonding
|
Bridges
|
Maryland Bridges
|
Implants
|
Dentures
|
© Contemporary Family Dentistry 2007 (new)