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Dental Emergency Virtual Consult
Please fill out the following information
First Name
Last Name
Date Of Birth
Gender
Email
Phone
How long has this been bothering you?
Location of discomfort you are experiencing:
Is the area sensitive to hot and/or cold?
Are you experiencing any swelling and/or bleeding?
Is the area sensitive when biting or applying pressure?
Any significant dental history with this area?
Please take a clear, well-lit photo of the area of concern
Upload
or drag files here
What medications are you currently taking?
Any allergy to the following:
Preferred Pharmacy and phone number:
Please take the following photos and upload them.
Front smiling view
Upload
or drag files here
Retracted view
Upload
or drag files here
Upper arch
Upload
or drag files here
Lower arch
Upload
or drag files here
Side profile
Upload
or drag files here
side profile bite
Upload
or drag files here
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