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 (make sure you submit individual x-ray instead of a full mouth of x-rays) 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 (e.g. treatment plan from your existing dentist or any information you would like us to know)
Payment
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KELLS Dental Second Opinion with AI Evaluation
$
49.00
Have an emergency?
If this is a dental emergency, click
here
to connect immediately to a teledentist.
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