Form

Request An Electronic Consultation

We are here to help during these times with virtual diagnostic evaluations and screenings to provide the safest care possible. We ask that you take a moment to fill out this form and attach a photo of the area in question. The fee for this virtual consultation is $59 and will be billed along with and exam. You may contact your dental insurance provider to verify coverage for codes D9995 and D0140.

Please fill out the Electronic Consultation Form below. If you would like us to make an appointment for other family members, please list the names on the message area.

Date

First Name

Last Name

Date Of Birth

Email address

Best number to reach you?

Time

Reason for virtual visit?

Pain? scale 1-10 sharpe/dull ache length of discomfort?

Sensitive? hot/cold

Swelling? where?

Have you had recent dental work?

When was you last visit?

Attachments: Please attach photos below

Upload or drag files here

Attaching photos of the area in question will assist us in a accurate diagnosis and help with insurance coverage for virtual visit.

Signature