Fisher & Surger Virtual Care Consultation Form

Virtual Care Consultation Form
Live consultations may be used to manage discomfort or pain, visual trauma assessments, or follow-ups, or if you are trying to manage dental disease or engage in better habits at home and need more guidance or reassurance.

*Prior to filling out this form* Using your phone's camera, please take at least 3 clear (non-blurry) pictures from different angles of the area of concern. Your camera's flash could be helpful to take pictures of molars or gingiva.
Child's Name *

First Name Last Name
Child's Date of Birth *

Month Day Year
mm-dd-yyyy
Phone Number *
Email *
New or Existing Patient *

New Patient Existing Patient
Has the Patient been to our office in the last 12 months *

Yes No
*Important* For our Existing Patients of record who have been seen in our office in the last 12 months:
- For urgent dental needs (trauma, pain, etc.), please contact us on our doctors' emergency mobile line: 949-478-2578 . Prior to calling, please use your phone's camera to capture and text us several photos of the area of concern.
- For less urgent dental needs , please continue to use the form below to submit a description of the concern and your photos.
- The $75 consultation fee will be waived.
Dental Insurance *

Active Not Active or Has Changed
*Note* We will help you to seek reimbursement from your insurance carrier or process claims once we return to the office, but please know this may be a non-reimbursable $75 consultation fee depending on your insurance policy and possibly used towards your exam frequency.
Insurance Information, including Subscriber's Name and Subscriber's Date of Birth
Please do not fill in any sensitive information like SSN
Insurance Card Picture 1
Insurance Card Picture 2
Changes in the Medical History (including allergies and medications)? *

Yes No
Medical History Changes
Please describe changes in Medical History (including allergies and medications)
Chief Complaint *

Trauma Pain and/or Swelling Other
Please Describe the Chief Complaint in Detail *
Attach 3 Pictures Below

Using your phone's camera, please take clear (non-blurry) pictures from different angles. Your camera's flash could be helpful to take pictures of molars.
Picture 1
Picture 2
Picture 3
Upload Additional Photos or Videos (Optional)
Parent/Legal Guardian's Name *

First Name Last Name
Relationship to Child *
Parent/Legal Guardian Signature *

Clear
Service Fee
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Virtual Care Consultation $ 75.00
Consultation Fee for Virtual Care Services

Total $ 0.00
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