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To schedule an appointment, please complete and submit the request form below. Our scheduling coordinator will contact you soon to confirm your appointment.</p> 186<p> 187 Please note this form is for requesting an appointment. If you need to cancel or reschedule an existing appointment, or if you require immediate attention, please contact our practice directly.</p> 188 <form action="assets/php/validator.php" class="forms recaptcha-form" method="post"> 189 <div class="input"><label>Name</label> <input name="Name" placeholder="John Smith" required="true" type="text" /></div> 190 <div class="input"><label>Phone Number</label> <input name="Phone" placeholder="(555)-555-5555" type="text" /></div> 191 <div class="input"><label>Email Address</label> <input name="email" placeholder="[email protected]" required="true" type="email" /></div> 192 <div class="input inline"><label>Are you...</label> 193 <span><input name="PatientType" value="New" type="checkbox" /> A New Patient </span> 194 <span><input name="PatientType" value="Existing" type="checkbox" /> An Existing Patient</span> 195 </div> 196 <div class="input inline"><label>Preferred day of the week</label> 197 <span><input name="day" value="Monday" type="checkbox" /> Monday </span> 198 <span><input name="day" value="Tuesday" type="checkbox" /> Tuesday </span> 199 <span><input name="day" value="Wednesday" type="checkbox" /> Wednesday </span> 200 <span><input name="day" value="Thursday" type="checkbox" /> Thursday </span> 201 <span><input name="day" value="Friday" type="checkbox" /> Friday</span> 202 </div> 203 <div class="input inline"><label>Preferred time of the day</label> 204 <span><input name="time" value="Morning" type="checkbox" /> Morning </span> 205 <span><input name="time" value="Afternoon" type="checkbox" /> Afternoon </span> 206 </div> 207 <div class="input"><label>How did you hear about us?</label> 208 <select name="discover"><option>Search Engine</option><option>Family/Friend</option><option>Promotion</option><option>Social Media</option><option>Other</option></select></div> 209 <div class="controls"> 210 211 <!--<div class="g-recaptcha alt-captcha-container" data-sitekey="6LfLMsoUAAAAAPsf-mxiM_xniGwzwhm3TY1lfFcI"></div> 212 <button class="submitBtn btn button">Send</button>--> 213<input type="submit" name="submit" value="Send" class="submitBtn btn button"> 214</div> 215<input type="hidden" name="token_generate" id="token_generate"> 216 <input name="_subject" value="Appointment Request" type="hidden" /><input name="_redirect" value="thanks.html" type="hidden" /></form></article> 217 </section> 218 219 <footer> 220 <div id="footer-contents"> 221 <div id="footer-info"> 222 <a href="/" class="logo"> 223 <img alt="Small logo Ronan Freyne, DMD" src="assets/images/logo-ronan-freyne-dmd.png"> 224 </a> 225 <a href="tel:3019860700" class="phone">(301) 986-0700</a> 226 <address> 227 <a href="https://goo.gl/VcLUso" target="_blank"> 228 2 Wisconsin Circle, Suite 620<br> 229 Chevy Chase, MD 20815 230 </a> 231 </address> 232 <span class="hours"> 233 <b>Monday:</b> 8:00 am - 2:00 pm<br /> 234 <b>Tuesday:</b> 8:00 am - 4:00 pm<br /> 235 <b>Wednesday:</b> 8:00 am - 4:00 pm<br /> 236 <b>Thursday:</b> 8:00 am - 4:00 pm<br /> 237 <b>Friday:</b> 8:00 am - 1:00 pm 238 </span> 239 <span class="social"> 240 <a href="https://goo.gl/VcLUso" target="_blank"><i class="icon-gplus"></i></a> 241 <a href="https://www.facebook.com/RonanFreyneDMD/" target="_blank"><i class="icon-facebook"></i></a> 242 <a href="https://www.yelp.com/biz/ronan-freyne-dmd-chevy-chase-3" target="_blank"><i class="icon-yelp"></i></a> 243 <a href="https://www.healthgrades.com/dentist/dr-ronan-freyne-xc7f6" target="_blank"><img src="assets/images/icon-hg.jpg" alt="Healthgrades icon" /></a> 244 </span> 245 </div> 246 <form action="assets/php/validator.php" class="forms recaptcha-form" method="post"> 247 <strong>Have Questions? Get Answers.</strong> 248 <div class="input"> 249 <input name="Name" placeholder="Name" required="true" type="text" /> 250 <input name="Phone" placeholder="Phone Number" type="text" maxlength="10" pattern="[0-9]{10}" /> 251 <input name="email" placeholder="Email Address" required="true" type="email" /> 252 <textarea name="question" class="fields" placeholder="How Can We Help You?"></textarea> 253 </div> 254 <div class="controls"> 255 <!--<button class="btn">Submit My Questions</button>--> 256 <input type="submit" name="submit" value="Submit My Questions" class="btn" /> 257 </div> 258 <input type="hidden" name="token_generate" id="token_generate" /> 259 <input name="_subject" value="Ask the Doctor" type="hidden" /> 260 <input name="_redirect" value="thanks.html" type="hidden" /> 261 </form> 262 </div> 263 <div id="footer-logos"> 264 <img alt="American Dental Association logo" src="assets/images/ada-logo.jpg" /> 265 <img alt="Academy of General Dentistry logo" src="assets/images/agd-logo.jpg" /> 266 <img alt="Maryland State Dental Association logo" src="assets/images/maryland-state-dental-association-logo.jpg" /> 267 <img alt="District of Columbia Dental Society logo" src="assets/images/district-of-columbia-dental-society-logo.jpg" /> 268 <img alt="American's Top Dentists logo" src="assets/images/americas-top-dentist-logo.jpg" /> 269 <img alt="Top Dentist logo" src="assets/images/top-dentists-2026-logo.png" /> 270 <img alt="This American Life logo" src="assets/images/this-american-life-logo.jpg" /> 271 <img alt="Good Morning America logo" src="assets/images/good-morning-america-logo.jpg" /> 272 <img alt="Top Dentist 2026" src="assets/images/invisalign-logo.jpg" /> 273 <img alt="Invisalign Logo" src="assets/images/top-dentist-2026.jpg" /> 274 </div> 275 <div id="copy"> 276 Copyright © <span id="copyDate"></span> Ronan Freyne, DMD | <a href="sitemap.html">Sitemap</a> |<br /> 277 <a href="privacy-policy.html">Privacy Policy</a> |<br /> 278 Site designed and maintained by<a href="https://www.tntdental.com/" target="_blank" title="Dental Website Design">TNT Dental</a> 279 </div> 280 </footer> 281 <div id="scroll-nav"> 282 <a href="request-an-appointment.html"> 283 <span><i class="icon-calendar-1"></i> Request </span><em>an Appointment</em> 284 </a> 285 <a href="office-visits.html#forms"> 286 <span><i class="icon-download"></i> Forms</span><em>Download Our Forms</em> 287 </a> 288 <a href="https://www.facebook.com/RonanFreyneDMD/" target="_blank"> 289 <span><i class="icon-facebook"></i> Like Us</span><em>Like Us on Facebook</em> 290 </a> 291 <a href="https://goo.gl/gptfcv" target="_blank"> 292 <span><i class="icon-gplus"></i> Reviews</span><em>Leave a Google Review</em> 293 </a> 294 </div> 295
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