Smile Assessment
 
In order to provide you a smile assessment and address your dental concerns, please submit your information below. 
 
Pictures must be provided. Depending on the nature of your concerns, the doctor may request additional pictures or a Virtual Consultation (VC) before he can proceed with smile evaluation and provide a treatment options. It is important to be aware that picture and video examination may not provide a definitive answer and patient will need to come to the office to do additional testing on the teeth and most likely need x-rays.
 
 
If you are a NEW PATIENT, before dentist can proceed with assessment, you will receive by email our "New Patient Packet."  All of the forms must be filled out and submitted. Once these are received, dentist will be in touch with you as soon as possible.These include:
  1. HIPPA Notice of Privacy Practices
  2. Patient Information
  3. Medical History
  4. Office Policies
  5. Financial Policies
 
If you are an EXISTING PATIENT, your information is on file. Dentist will be in touch with you as soon as possible.
 
The cost of an smile assessment is $75. New Patients will be charged once all required forms in packet have been submitted. In the event, the dentist requests more information through a Virtual Consultation, the fee is $125. Many insurances reimburse for these service; however, patient is responsible for payment regardless of dental insurance reimbursement.
 
Please have your credit card information ready. You will need to fill out credit card information before request can be submitted. 
 
All of your information is securely sent back for evaluation.
 
It is important that patients be aware that a TeleDentistry questionaire helps to narrow down what their potential treatment needs might be, but may not provide a definitive answer.  An Virtual Consultation and/or in-office visit may be needed for additional testing on the teeth and x-rays before a treatment plan can be provided.
Patient Tips for Setting Up Phone for Photos 
(Please note that patient will have to put their fingers in their mouth to move their lips and cheeks and move their head in certain ways).
 
Before taking photos:
 
  • Wipe phone with disinfectant.
  • Wash your hands with soap and water for 20 seconds.
  • If facilities are unavailable, use hand sanitizer.
  • Avoid touching any surfaces after you have washed your hands.
When taking photos:
 
  • Have the light source behind the phone
  • As an alternative, make sure the screen is as bright as possible
  • Set the camera so it is propped up horizontal and set it close to the edge of the table/desk. (this makes it easier to get close to the camera if needed.
  • Make sure the camera is in "selfie" mode
  • Turn the flash on with the time (3-10 seconds recommended) when photos inside the mouth are requested.
 
After taking photos:
 
  • Immediately wash your hands for 20 seconds.
  • If you can't wash your hands, use hand sanitizer.
  • Wipe any surfaces around them with disinfectant wipes
Smile & Profile
Please Take The Above Photos
Upload or drag files here
Overbite & Overjet
Please Take The Above Photos
Upload or drag files here
Upper Arch & Lower Arch
Please Take The Above Photos
Upload or drag files here
Right Bite & Left Bite
Please Take The Above Photos
Upload or drag files here
By providing your email and cell phone number, you are consenting to receive emails, calls and/or SMS/MMS messages, including automated calls and texts.
Informed Consent
 
As validated by my signature on the bottom of this form:
 
I am acknowledging that I wish to receive this TeleDentistry evaluation from Dr. Plastow.
 
In the absence of radiographs (x-rays), I understand that I may be asked to send photographs or other documentation as requested by the dentist.  I will try to provide as much detail as I can.  I understand that the doctor is limited to what he is able to determine in these circumstances. 
 
I understand that the doctor may request follow-up to this TeleDentistry Questionaire with either a Virtual Consultation or an in-office visit so that he can further evaluate and discuss your dental treatment options.  It goes without saying, that dental procedures can only be provided with in-office visits. 
 
I also understand that if I am experiencing pain or swelling that is life threatening, I will call 911 or go to the emergency room. 

I understand and consent to this consultation being recorded for clinical documentation and accuracy. 
 
I understand that I am responsible for any payment resulting from this consultation and that payment is due at the time of service, regardless if treatment is covered under my insurance plan. I understand that Dr. Plastow's office will submit forms for payment and you will be reimbursed if provider covers your TeleDentistry visit.

Please provide credit card information below.