Oral Pathology Virtual Consult

Oral Pathology Virtual Consult

Virtual provider-to-provider consult fee: $40
Name (DDS/DMD name)*

First NameLast Name
Provider (Dentist) Identity

(REQUIRED)
Practice Name
Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State of Licensure *
Dental License Number *
Email*
example@example.com
Confirm Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number (not required)
Please enter a valid phone number.Format: (000) 000-0000.

Patient Case Information

PHI is allowed since this is a HIPAA compliant form
Patient Initials (example: JP) *
Patient Age*
Relevant Medical History*
Patient Medications*
Location in Oral Cavity (for example: right buccal mucosa, left lateral border of tongue, palatal to tooth #3)*
Chief Concern*
Duration of Lesion*
Clinical Photo Upload*

Multiple files allowed - these files are encrypted
Cancelof
Date Patient Seen
Additional Date (if older photos included)

Please sign below before continuing to payment options*

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Provider (Dentist) Identity