Video Consultation Form

Your name

Your Email

Phone number

Have we seen you before?
Yes, I am an existing patientNo, I am a new patient

What is your dental emergency?

Please note what times are convenient for your consultation (check all that apply). Our office hours are subject to changes dependent on guidelines for COVID-19. We will be in touch to confirm all appointments.
Early morningMid-morningEarly afternoon

All payment information should be supplied over the phone or in person at the office for added security.
I have read and understand the above statement.