Teledent Patient Intake Form

Request a Dental Evaluation

Fill out the form below to request an evaluation. You will receive an invitation to login to our patient portal via text or email after submission where you can communicate with your provider.

Fields with an * are required.

First Name

Last Name

Gender

Date of Birth

Registration Method

Email Address

Primary Phone Number

What is your problem/concern? (Choose all that apply)

toothache/pain

crown fell off

broken tooth

lost tooth

loose tooth

bleeding gums

broken denture

other

Please describe your dental problem/concern.

Attach images or documents to help explain your concern.

Upload