Receive A Virtual Consultation

First Name:

Last Name:

Phone Number:

E-mail Address:

Date of Birth:

Procedures:

If treatment is required, please select your preferred office location

For all procedures, please upload photos/x-rays of your teeth and/or gums and any additional photos that may help us accurately determine the appropriate treatment for you. Maximum File upload Size is 500 MB.

Photo/X-ray Submission

Please upload a photo of your Driver's License & a photo of your Dental Insurance Card using the fields below.

Driver's License

Insurance Card

Why are you seeking treatment?

Medical History:

Are you a new patient? if so, please download and fill out the New Patient Form by clicking here.

Please download your Consent for Treatment form by clicking here.

When you have completed your form(s), please upload it using the field below.
(you can select multiple files by holding the CTRL button for PC or COMMAND Button for MAC while clicking files)

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 MK Periodontics & Implants, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.

By checking this box, I acknowledge my understanding of the HIPAA Policy and agree with its contents.