Your Smile Destination

This form is for traveling patients only. If you are local to the Springfield, MO area, please give us a call at 417-889-4746.
Name*

First NameLast Name
Phone Number*
Email*

Confirmation Email
Date of Birth*

MonthDayYear
Address - City & State*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Unfortunately, we are unable to offer virtual consultations to those outside of the United States at this time.
How did you hear about Innovative Dental?

Innovative Implant Smile WebinarInstagramYouTubeFacebookGoogleFriend/Family Member
Do you intend on traveling to Springfield, MO to receive dental treatment by Dr. Olson?*

YesNo
Once we receive current x-rays, Dr. Olson will review your case and a team member will contact you to schedule a virtual consult. A non-refundable deposit of $150 is required to schedule the virtual consult. Should you move forward with treatment at our office, the $150 deposit will be applied to the cost of your treatment.
Unfortunately, Dr. Olson is unable to offer individual second opinions at this time.
How many teeth are you interested in fixing?*

Just a few.Full Top ArchFull Bottom ArchFull Mouth
When was your last dental visit?*

Less than 1 Year2 - 4 Years5 - 9 Years10+ YearsNot Sure
In order to proceed with a Virtual Consultation with Dr. Olson, we will need current x-rays. Upon submission of this form, you will receive information on sending your x-rays.
In order to proceed with a Virtual Consultation with Dr. Olson, we will need current x-rays. Since it has been more than two years since your last dental visit, we recommend finding a local dentist to take x-rays. Upon submission of this form, you will receive information on sending your x-rays.
Are you currently in Invisalign or traditional braces?*

YesNo
Any buttons or brackets will need to be removed prior to receiving treatment at Innovative Dental.
What treatments are you interested in?*

VeneersImplantsAccelerated InvisalignFillingsCrowns
Have you looked into the selected treatments before?*

YesNo
Do you currently have dental insurance?*

YesNo
What dental insurance do you currently have?
Dental Insurance Plan Company
Please be aware that we are not a Medicare/Medicaid provider.
Is this an individual plan or is it through your employer?*

IndividualEmployer
What is the name of your employer?
Are you the subscriber on the policy?

YesNo
Subscriber's Name
Subscriber's Date of Birth

MonthDayYear
Many cosmetic and implant procedures are not covered by dental insurance.
Have you given thought into how you'll be financing your treatment?*

Yes: Self-PayYes: FinancingNo
Financing Options

I will secure my own financing.I would like to receive information on financing options.
Tell us about your current smile.*
What is your goal for seeking care at Innovative Dental?*
Full Face Photo*
Up Close Smile Photo*
Upper Arch Photo*
Lower Arch Photo*
Bite Photo*
Your form is not fully submitted until you see the confirmation message. Depending on the size of your images and connection speed, it could take a few minutes to submit.
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