Patient's Name
*
First
Last
Patient's Age
*
Please enter a number from 0 to 99.
Patient's Birthday
*
-
Month
-
Day
Year
Patient's Gender
*
New or Existing Patient
*
New Patient
Existing Patient
Cell Phone Number
*
The number you would like the office to call or text
E-mail
*
Confirmation Email
Medical Conditions
*
Pharmacy Name
Pharmacy Phone Number
Chief Concern
*
Trauma
Pain
Swelling
Cavities
Other
Description
*
Example Photo #1
Example Photo #2
Please pull the patient's lip down and keep the tongue out of the way to ensure maximum visibility of the area of concern. Make sure to take the photo in a well lit area and verify that the photo is in focus. The quality of the picture may affect the accuracy of the diagnosis. Taking photos from multiple angles is also recommended.
Upload Picture #1
*
Browse Files
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of
Upload Picture #2
*
Browse Files
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of
Consent
*
Signature of the Parent/Legal Guardian
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
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