Form

TeleDentistry Request During COVID-19

If following this teledentistry consult, an in person appointment is recommended:

PER GOVERNOR DUCEY'S EXECUTIVE ORDER ON 3/19/2020, we are able to see patients for EMERGENCY/URGENT NEEDS described by the ADA. Listed below are the some of the situations that constitute an appointment that we receive high calls for:

Severe dental pain from pulpal inflammation
Abscess or localized bacterial infection with pain and swelling
Tooth fracture resulting in pain or causing soft tissue trauma
Final crown/bridge cementation if temporary is lost, broken or causing gingival irritation
Extensive dental caries (decay) or defective restorations causing pain. Manage with SDF and glass ionomer treatment
Denture adjustments or repairs when function impeded
Snipping or adjustment of orthodontic wire or appliances (Partial dentures) piercing or ulcerating tissue

**WITH NON-COMMUNICATIVE PATIENTS, WATCH FOR BEHAVIORS THAT DISPLAY ORAL PAIN

**HELP CONSERVE HOSPITAL BEDS AND PHYSICIAN CALLS BY UTILIZING SMILES BY DELIVERY FOR DENTAL EMERGENCIES.

Is this consultation for a patient of record with Smiles by Delivery?

IS THIS PERSON STATING PAIN OR IS THIS NON-COMMUNICATIVE PERSON DISPLAYING PAIN?

Do you feel that this is an urgent situation (as described in the ADA's EMERGENCY/URGENT NEEDS link above) to warrant an in-person visit?

If you are not a patient of record, you will be required to complete our new patient registration. CLICK HERE or find our registration at SmilesByDelivery.com under Patient Information

Patient's First Name

Patient's Last Name

DOB

Consultation for:

DOB

Email of Responsible Party

Cell Number of Responsible Party

Your Message: (include details of your concern, who to contact and best way to contact)

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Date