Skip to content

    Patient Information

    Name (required)

    Email

    Parent/Guardian

    Date of Birth (required)

    Phone (required)

    Treatment Information

    Areas of Concern (required)

    Does the patient require antibiotics before treatment? (required)

    Radiographs/Clincial Photos
    Being MailedGiven to PatientPlease TakeNo X-Ray

    Upload X-rays


    If X-Rays are attached, what date were they taken?

    Referring Doctor Information

    Referring Doctor's Office (required)

    Email (required)

    Additional Comments