Virtual 2nd Opinion Form
Please complete this brief form. We will contact you to schedule a consultation.
I would prefer to discuss my dental health and questions with Dr. Wegner:
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On an Introductory Call
On a Video Conference
At a Free Office Consultation
Choose one or two of the 2nd Opinion topics listed below that are most important to you:
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Discuss recommendations from another dentist for myself or a family member
How to Solve Chronic Teeth or Gum Problems that Have Been Frustrating or Costly
I Avoid Dental Visits Due to Past Negative Experiences or Residual Fears
I Do Not Love My Smile & Want to Understand Options To Make It More Attractive
I Have Had Past Dental Failures & Would Like to Understand How to Assure Good Outcomes
Another Topic (Explain Below In Additional Comments & Concerns)
Name
*
First Name
Last Name
Email
*
Phone Number
*
-
Area Code
Phone Number
Your e-mail address and personal information are confidential
and will not be sold or rented.
I was referred to Town & Country Dental Care by (Optional):
Additional Comments & Concerns (Optional):
Submit
Should be Empty: