Virtual Consultation First Name: Last Name: Are you a current patient? yes no Patient/Guardian: Contact Telephone Number: Email: Are there any changes to medical history? yes no Explain: Chief Complaint: Upload an Image: Upload an Image: Description of Problem: Insurance Company: Insurance ID: I agree to my dentist billing my insurance company for the tele consultation and I give consent to them to view the images or show it another medical/dental provider for diagnosis and treatment options. Clear Show points? Signature Date Submit Secure Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.