Emergency / Teledentistry Request

Please fill out the form below for our team to provide you with the information and instructions for the Teledentistry session.
Patient Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Please describe the nature of your child's concern*
- Infection/Swelling
- Trauma
- Tooth Pain
Additional Notes for the Doctor
Please select your relationship to the child*
- Select All
- Mother
- Father
- Legal Guardian
- Other
Clicking the box and providing my signature is my consent for the information below*

I consent to have a remote oral examination by the pediatric dentists via Teledentistry means implemented by Smile Wonders.

I understand that there is $255 non-refundable fee associated with the emergency teledentistry services whether provided during office hours or as an afterhours emergency support.

I am responsible for payment at the time of service.
Signature*
Date
MM slash DD slash YYYY