william a vitalie, dmd | aesthetic & restorative dentistry | find your ideal smile

 
   
 
Request An Appointment | Complimentary Smile Consultation
 
Which office location is more convenient for you?
 

 Indiana PA

 

Pittsburgh PA

 

 
Tell us a little about yourself...  
First Name   Last Name  
Middle Name   Preferred Name  
Address   Address (line 2)  
City   State  

Zip

 
Phone (day)      Phone (eves)    
  example: (123)456-7899 or 123-456-7899   example: (123)456-7899 or 123-456-7899
Cell Phone   Email Address  
  example: (123)456-7899 or 123-456-7899   example:  johnsmith@yourisp.com
Birth Date

 

Sex  
 example: 01/01/1980 or 01-01-1980

 
Which Days do you prefer for an Appointment?  

Mon   |    Tues   |    Wed   |    Thurs   |    Fri   |    Sat

It changes each week


 
Which Time Blocks do you prefer for an Appointment?  

7am-9am   |   10am-12pm   |   12pm-2pm   |   2pm-5pm   |   5pm-7pm

It changes each day


 
If you could change anything about your smile, what would it be?  
Whiten Teeth        Straighten teeth Lengthen teeth
Shorten teeth Replace missing teeth Fix space between teeth  
Replace old silver fillings Make smile less 'gummy' Everything!  Need a smile makeover
Other (please explain)        

 
How did you find our Website?  
Search engine   LVI website Link from another website
Television ad Newspaper ad Magazine ad or article
Family or Friend  Other (please explain)

 
Do you have any specific concerns you would like to speak with Dr. Vitalie about?

 

         

  Indiana PA  724.349.8380   |   Pittsburgh PA  412.521.4300
  questions:  info@vitaliesmiles.com    |    appointments:  office@vitaliesmiles.com
   

 

Copyright 2005  William A Vitalie, DMD
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