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.
Did you have a Head, Neck or Jaw injury?
When did this happen?
Did you break any of your teeth/fillings/crowns?
What tooth (or area of your mouth)?
Do you feel pain in any of your teeth?
Is this pain constant?
Is this pain severe?
Are your teeth sensitive to hot/cold or sweet liquids/foods?
If your broken tooth / filling is sharp, would you like us to smooth it down?
Is there any swelling around your tooth?
Is there any swelling in your cheek/face?
Have you been taking any medication for pain/infection?
Please list medications:
Have you ever had Periodontal Treatment (scaling, bone surgery, gum grafting)?
Do your gums bleed while brushing or flossing?
Are any of your teeth loose?
Do you have any sores or lumps in or near your mouth?
How long do you think it/they have been there?
Are you experiencing any of the following problems in your jaw?
Pain (Joint, ear, side of face)
Difficulty in opening, closing, or chewing?
Do you clench or grind your teeth?
Do you bite you lips or cheeks frequently?
Have you noticed any loosening of your teeth?
Ever worn a Night Guard or other Appliance? (Please bring to your next appointment to evaluate)
Do you wear Dentures or Partials? (If yes, date and placement below)
Year they were made:
Where were they made?
Notes, Comments, or Questions
If you are able to,
please take a photo like these
that shows the area(s) you are calling about.
1 - Please take one of the above photos.
(If both arches are bothering you, take both.)
2 - Upload the photo(s) by clicking the Upload button below.
or drag files here
Date Of Birth
Preferred Contact Method
Preferred Contact Time