Dental History & Concerns
Please describe your current dental concerns or issues: (e.g., old root canals, mercury fillings, jaw pain, gum inflammation, etc.)
What improvements or results are you hoping to achieve? (e.g., better aesthetics, relief from pain, improved oral health, etc.)
Have you received any prior dental treatments that you’re unhappy with?
Have you received any prior dental treatments that you’re unhappy with?
Yes
No
Do you have any of the following concerns? (Check all that apply)
Preferred Method of Contact
Preferred Method of Contact
Email
Phone
Do you have any relevant medical conditions or allergies? (e.g., metal allergies, chronic illnesses, etc.)
Have you had recent dental imaging (e.g., CBCT scans, X-rays)?
Have you had recent dental imaging (e.g., CBCT scans, X-rays)?
Yes
No
Preferred Appointment Details
(We will do our best to accommodate your request.)
Would you like assistance scheduling an in-person appointment after your virtual consultation?
Would you like assistance scheduling an in-person appointment after your virtual consultation?
Yes
No
Supporting Documents
Please email any supporting documents, including 3D CBCT scans, X-rays, or photos, to [email protected]
Click here to submit your request. A member of our team will contact you shortly with the next steps.
