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.  
 
 
 
Smile & Profile of affected area
Please Take The Above Photos
Upload or drag files here
Upper Arch/Lower Arch where the tooth is located
Please Take The Above Photos
Upload or drag files here
Right Bite /Left Bite of affected tooth
Please Take The Above Photos
Upload or drag files here