Patient Consultation Form

Consultation Form

Request an appointment with Dr. Michino & Dr. Jackson
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMaleOther
Email
example@example.com
Phone Number*
Please enter a valid phone number.
OUR OFFICE WILL CALL YOU ASAP

Someone from our office will call you to schedule a consultation. If possible, please have your insurance information available to speed up the approval process.
Language Preference

EnglishJapaneseOther (Require a Translator)
Preference of Surgeon

Dr. James MichinoDr. Harry JacksonSoonest Available
APPOINTMENT TIMES

Consultation appointments are typically 30-minutes long. You may be asked to come in early to take X-Ray's or CBCT scans to aid in diagnosis. This will be discussed in detail during when scheduling your appointment by phone, but you should budget about one hour to be at our office.
Name of Your Local Dentist*
If you don't have a dentist, please put "None"
Consultation Type*

Wisdom Teeth RemovalDental ImplantsReconstruction SurgeryBone GraftingSecond OpinionDiagnosis HelpOther
More details about your condition...
Please explain why you want to meet with a surgeon. Detailed information helps us, help you!
Have you had oral surgery before?

YesNo
Please upload medical documents (if any)

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Please verify that you are human*
By submitting this form, you agree to being contacted by phone and email by Hawaii Elite Oral Surgery.
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