• Select your service*
  • What Hurts?*
  • What do you think is wrong with your tooth?*
  • What type of aligners do you have?*
  • What do you think is wrong with your gums or soft tissue?*
  • What kind of appliance do you have?*
  • What do you think is wrong with your Braces/Aligners/Spacers?*
  • What do you think is wrong with your denture or partial denture ?*
  • Where is the problem located?*
  • Left or Right?*
  • Front or back?*
  • Cheek or Tongue side ?*
  • Has this been an area of concern before ?*
  • Has a dentist ever discussed periodontal disease?*
  • When was your last inspection?*
  • When is the last time you had a professional cleaning ?*
  • What was your last exam?*
  • Do you clench your teeth ?*
  • Do you consume tobacco products?*
  • Do you have frequent sinus issues?*
  • How long has this been a problem?*
  • Was the affected tooth worked on by a dentist previously?*
  • What work was done?*
  • In general are you happy with your denture?*
  • Does your tooth hurt to hot or cold?*
  • Is the pain temporary or persistent?*
  • Does the tooth hurt to biting?*
  • How severe is the pain?*
  • How would you describe the pain?*

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  • What are your main concerns ?*
  • Are you currently a patient of this practice?*
  • Will this change a specific area of your life?*
  • Have you spoken to another dentist about this?*
  • What was your experience like?*

  • How can we reach you ?

  • Format: (000) 000-0000.
  • Do you have insurance?*

  • Snap a photo

    Please use a spoon or something similar to widen your mouth for the best images and good lighting is helpful. High quality images are required for an accurate assessment and if they are not provided, the consultation may not be completed by the doctor. It may be helpful to have someone assist you for the best outcome.
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  • Last Step

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