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:
- HIPPA Notice of Privacy Practices
- Patient Information
- Medical History
- Office Policies
- 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.