TeleDENTUS

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Preferred Doctor

Dr. Chen

Dr. Nguyen

Dr. Stephanie Huynh

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?

Patient Name and Age

Parent / Legal Guardian Name:

Phone:

Dental Insurance Company (if any) (include your Subscriber ID)

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

Questions related to pain and swelling below.

Is there any swelling? Is there trauma involved (accident, fallen on face, etc)?

Where is the problem (in your mouth):

Back of mouth

Front of mouth

Lower left

Lower right

Upper left

Upper right

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

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

Zoom

Questions related to COVID-19.

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 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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