TeleDentistry Emergency Assessment
Dental Emergency
 
In order for the dentist to assess your dental emergency, please submit your information below. Each question must be answered in order to proceed through evaluation and for you to be able to submit your request for consultation.
 
Pictures are optional; however, the doctor may request pictures before he can proceed with evaluation.  Additionally, a virtual consultation may be required in order for the dentist to provide a thorough evaluation and provide treatment options.
 
If you are a NEW PATIENT, you must complete our "New Patient Packet" before dentist can continue with your evaluation. The forms will be sent by email and can be filled out online. All of the forms must be filled out and submitted. Once these forms are received, the dentist will be in touch with you as soon as possible. The packet includes:
  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 emergency evaluation is $75. Payment will be charged to the credit card you provide below. New Patients will be charged once all required forms in packet have been submitted. In the event, the dentist requests more information through a TeleDentistry Virtual Consultation (VC) the fee is $125. Many insurances reimburse for this service; however, the 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 your 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 the patient's 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 can be provided.
Have you ever experienced any of the following problems in your jaw:
Patient Tips for Setting Up Their Phone for Photos 
(Please note that the 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 you 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 Emergency Questionaire with either a Virtual Consultation or an in-office visit so that he can further evaluate and/or 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. Credit card payments only are accepted.

Please provide credit card information below.