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Dental ERx
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Synchronous (Live) Consultation
FAQ
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We make great smiles affordable
We provide compassionate, comprehensive dental care tailored to every age and stage of life
Full Name
*
Address
Date of Birth:
Phone Number
*
Email Address
*
Dental ERx is currently available in the following states
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Select States
Alaska
Arkansas
California
Delaware
Florida
Georgia
Illinois
Indiana
Kentucky
Maryland
Mississippi
Missouri
New Jersey
Ohio
Pennsylvania
South Carolina
Tennessee
Texas
Vermont
Washington
Preferred Pharmacy (Name & City/State, phone number)
*
What is the reason for your visit today?
Check all that apply
Wisdom tooth
Tooth pain
Broken tooth
Swelling
Infection
Other
Important Notice Please seek emergency medical services immediately if you are experiencing a medical emergency, including chest pain, head or eye injury, broken bones, or difficulty breathing.
Please select your pain level
Mild
Moderate
Severe
Extreme pain
Are you experiencing any of the following?
Swelling
Sensitivity
Fever
Pus or drainage
Bad taste
Difficulty chewing
Difficulty opening mouth
Area of Concern Side:
Right
Left
Location:
Upper
Lower
Position:
Front
Back
Optional Description:
Upload file
Photo Upload is optional but recommended.
Choose File
No file chosen
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Medical Information
Do you have any drug allergies?
No
Yes
Do you have any medical conditions?
No
Yes
Are you currently taking any medications?
No
Yes
Choose Consultation Type
*
Choose Consultation Type
Synchronous (live) Consultation ($35)
Credit / Debit Card
*
I agree By selecting this box, I acknowledge and consent to the virtual dental services described above. I understand this consultation is provided via telehealth, consent to treatment, and authorize payment. I recognize that selecting this box serves as my virtual signature.
Click here to view Dental ERx Treatment Consent, Payment Policy and Authorization
Agreement
*
I have read and agree to the Dental ERx Telehealth Consent, Payment Policy, and Authorization listed above.
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