TeleDENTUS

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Preferred Doctor

Dr. David O'Connor

Dr. Jane Doe

Dr. Joel Steinberg

Dr. John Doe

No Preference

Are you a new or existing patient?

I am a new patient

I am an existing patient

Who may we thank for referring you to our office?

Parent Name / Legal Guardian Contact Info:

Patient Name and Age

Questions for the Doctor / Description of the problem / Second opinion questions:

Questions related to pain and swelling below.

Is there any swelling on your face or inside your mouth? Is there trauma involved (accident, fallen on face, etc)?

How strong is the pain (0 - no pain, 10 - extreme pain)? Enter a pain scale number 0-10:

Can you tolerate this discomfort or pain for another 2-3 weeks?

No answer

Yes

Do you have spontaneous pain? (It hurts while watching TV. It hurts while doing nothing in general.)

No answer

Yes

Do you have lingering pain? (You stopped drinking something hot/cold and you still have pain 15 mins later. You stopped eating and you still have pain 15 mins later.)

No answer

Yes

If you think you will need medication - Pharmacy name - Pharmacy address - Pharmacy phone number

Are you allergic to any medications?

Do you use any of the following:

Facebook Messenger

Facetime

Google Hangouts

Signal

Skype

Questions related to COVID-19. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment. Health Department Websites: https://www.cdc.gov/publichealthgateway/healthdirectories/healthdepartments.html

Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

No answer

Yes

Have you tested for COVID-19?

No answer

I am awaiting results from a COVID-19 test.

I have not taken a COVID-19 test

Yes

Have you been in close proximity with someone who tested positive for COVID-19 or has symptoms related to COVID-19?

No answer

Yes

Have you had the following symptoms the past 14-21 days?

Chills

Cough

Fever

Headache

Loss of smell and taste

Shortness of breath or difficulty breathing

Stomach ache

Tiredness

HIPAA ACKNOWLEDGEMENT Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold the requested Dental Office, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties. By selecting yes, I acknowledge my understanding of the HIPAA Policy and agree with its contents.

No answer

Yes

If your discussions with the Doctor becomes a consult conversation, your insurance will be billed for this consult. Anything not covered by insurance will be the patient's responsibility. Your Doctor will inform you ahead of time if the consult will require billing.

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