Name*

E-mail*

Phone Number*

Preferred Appointment Date

Preferred Appointment Time
08:30 AM 09:00 AM 09:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM Lunch - Closed 02:00 PM 02:30 PM 03:00 PM 03:30 PM 04:00 PM

Questions/Comments

No Interest Payment Plans
3 months — 1.5% MDR
For treatments of $99 or more

6 months — 2.75% MDR
For treatments of $299 or more

12 months — 5.95% MDR
For treatments of $499 or more

18 months — 10.95% MDR
For treatments of $599 or more

Budget Payment Plan
For treatments costing
$1000 or more — 4.5%
(at 12.96%)

Regular Revolving Credit
No min. purchase — 1.5% MDR

5900 Wisconsin Ave. Chevy Chase, MD 20815 (the NE corner of Wisconsin and Cumberland)

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