Form

Virtual Consult Request

In order to provide you a virtual consultation and assess your dental concerns, please submit your information below.

I understand that this request for a virtual consultation, and its system, is not monitored 24/7 and that all true emergencies should dial 911 go to the nearest emergency center.

STOP!!!

CALL 911,

or go to your nearest Emergency Room!

Do you have any pain in your teeth?

Do you have any sores or lumps in or near your mouth?

Are any of your teeth chipped, cracked or broken?

Have you had any injuries to your head, neck or jaw?

Please write a description of your dental emergency below

What is the reason for your Virtual Consultation Request?

What Type of TeleDentistry Consultation are you requesting?

I understand that TeleMedicine/TeleDentistry is a Service provided by the provider and its office technologies and that this service will be billed at the appropriate service level fees listed above for the appointment that is scheduled for you by the office.

Payment in full for services will be due either at the end of your session by credit card, or by a mailed statement.

If you have insurance, several insurers are paying for TeleDentistry Services in the wake of COVID-19 to help alleviate unnecessary visits to the dental office and to help provide care in times of restricted services, and further.

In addition, TeleDentistry can provide convenient services, in limitation, around busy schedules.

Our office will attempt, as courtesy, to bill any insurance prior to sending a statement for any unpaid balances.

PRESCRIPTION POLICY: The Standard of Care includes seeing the patient IN PERSON before issuing a prescription of ANY TYPE. IF the patient has been in continuing care, the doctor MAY issue a refill over the phone.

Do you believe you MAY need a prescription?

What Pharmacy would you use?

Pharmacy Phone Number

Pharmacy Description/Location

Check if you have taken any of the following medications in the past WITHOUT ANY PROBLEMS:

Have you had any allergic or negative reactions to any medications in the past? If so, List medication.