Form

Request An Electronic Consultation

Please fill out the Electronic Consultation Form below and attach all relevant images.

If this is for an emergency during office hours, please contact our office at (617) 731-5437. Our doctor on call will be available for after hours emergencies until 8pm. We do our best to respond as quickly to our patients requiring immediate care. Please fill the triage form below as accurately as possible, include pictures and your dentist will call you as soon as possible to the number you have provided below. If this is an emergency after hours, or you are unable to get in touch with the doctor on call, please go to your local emergency room.

Date

Patient First Name

Patient Last Name

Date Of Birth

Cell Number

Your Message

Attachments: Please attach photos below that provide more information about the emergency

Upload or drag files here

I understand that Teledentistry, the remote provision of dental care, advice, or treatment through the medium of information technology, allows us to triage the patient's dental problem. Claims for such procedure can usually be filed to your insurance as a limited exam and may be paid as if you were in office. Otherwise, the fee for such a visit is equivalent to a limited exam in our office. I give consent to them to view the images or show it to another medical/dental provider for diagnosis and treatment options.

By signing below, I hereby acknowledge that I have completely read and fully understand the above information.

Signature of Guardian or Patient (18+ years of age)

Name of Guardian or Patient (18+ years of age)

Relationship to Patient