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Virtual Consult - Dental Emergency
Please complete ALL forms prior to submittal for accurate billing to your dental carrier.
Dental Emergency
In order to provide you a virtual consultation and assess your dental concerns, please submit your information below.
Your information will be securely sent back to our team to evaluate.
CDT Code Billed
Teledentistry Code billed
Is your child experiencing severe pain?
Have you administered pain medication? Time given.
Is your child experiencing swelling?
Are your child's teeth sensitive to hot/cold?
Does your child have any sores, bubbles or lumps in or near their mouth?
Any known allergies to medication?
Name of medication(s)
When did this incident start?
Where is this issue located in the mouth? (Looking directly at the patient) Right, Left, Upper, Lower
Who is your regular Pediatric Dentist?
Smile & Profile of affected area
Please Take The Above Photos
File Uploader
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or drag files here
Upper Arch/Lower Arch where the tooth is located
Please Take The Above Photos
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or drag files here
Right Bite /Left Bite of affected tooth
Please Take The Above Photos
Upload
or drag files here
Patient Name
Patient Last Name
Patient Date Of Birth
Billing Information
Phone
Email
Address
City
State
Zip Code
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