Things to do to prepare for Teledentistry Evaluation, Fill out forms below and Submit
Downloadable Forms Available
Informed Consent
Name
Email
I am acknowledging that I wish to receive a teledentistry consultation with my dentist. In the absence of radiographs (x-rays), I understand that I may be asked to send photographs or other documentation as requested by the dentist. I will try to provide as much detailed if I can. I understand that the doctor is limited to what they are to determine n these circumstances. I also understand if I am experiencing pain or swelling that is life threatening, I will call 911 or go to an emergency room. I understand that I am responsible for any payment resulting from this consultation that is not covered by a dental insurance plan.
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Insurance Company Name
ID#
Group#
Insurance Company Address
