24-7 Emergency Dental Clinic

Medical Record Form for Emergency Virtual Consultations

Full Name *

Email *

Date of birth

Phone *

Medical History:

Dental Information:

Consent for Virtual Consultation:

I understand that the virtual consultation will be conducted by a licensed dental professional and that medications may be prescribed based on the information provided and the assessment made during the virtual consultation.

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I accept the company's terms and conditions. By giving my phone number, I consent to receive text messages.. To opt-out, reply "STOP".