Dental Second Opinion Submission Form
Name
*
First Name
Last Name
E-mail
*
example@example.com
Gender
*
Please Select
Male
Female
N/A
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Date of birth
*
-
Month
-
Day
Year
Zip code
*
Organization Code
Event Code
Upload your X-rays and photos
You may upload maximum 40 images including either X-rays (please submit individual x-rays instead of fmx or pano) or photos. All images must be valid type, e.g. jpg, jpeg, png.
Upload dental images
*
Upload a File
Drag and drop files here
Choose a file
Upload may take a few moments, make sure all images are listed before submitting.
Cancel
of
More details (any information you would like us to know)
Have an emergency?
If this is a dental emergency, click
here
to connect immediately to a teledentist.
Payment
Please note your case will not be processed until the payment is successful.
Service
*
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The TeleDentists + KELLS Dental Second Opinion with AI Evaluation
$
95.00
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