Telehealth Consultation Request

First and Last Name*

Date of Birth*

Gender*
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Email

Smart Phone*

How would you like us to contact you?*
Please call me at the number providedPlease text me at the number providedPlease contact me by email

Preferred time of consultation*
8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM

Preferred language*
EnglishSpanish

Are you a new patient?*
YesNo

Briefly describe the reason for requesting an online consultation*

PHI Disclaimer: Information collected from this website or provided on any form you have submitted through the website is used only in conjunction with an interest by the user in obtaining additional information at the Herman Ostrow School of Dentistry. This information is not considered Protected Health Information (PHI) and will be used to contact you because you have requested that you be contacted. In addition, information provided on the website or in any response to you is not and cannot be considered medical advice or treatment.

I agree with the above PHI Disclaimer*

Teleconsult Disclaimer: The information contained in these topics is not intended nor implied to be a substitute for professional medical advice, it is provided for educational purposes only. You assume full responsibility for how you choose to use this information.
Always seek the advice of your physician or other qualified healthcare provider before starting any new treatment or discontinuing an existing treatment. Talk with your healthcare provider about any questions you may have regarding a medical condition. Nothing contained in these topics is intended to be used for medical diagnosis or treatment.

OFPOM TeleConsult:

• Not a Substitute – The information and materials you receive through a OFPOM teleconsult should not be used as a substitute for the care and knowledge that your dentist or physician can provide to you.
• Supplement – The information and materials presented at a OFPOM teleconsult are meant to supplement the information that you obtain from your dentist or physician. If there is a disagreement between the information presented herein and what your physician has told you — it is more likely that your dentist or physician is correct. He or she has the benefit of knowing your medical problems and will have performed a direct physical examination of your head, mouth and neck region.
• Limitations – You should recognize that the information and materials presented to you during a OFPOM teleconsult have the following limitations, in comparison to being examined by your own physician:
  • Your doctor can perform a physical examination and any necessary tests.
  • You could have an underlying medical problem that requires a physician to detect.
  • If you’re taking medications, they could influence how you experience various symptoms.

If you think that you are having a medical emergency, call 911 or the number for the local emergency ambulance service NOW!
When in doubt, call your doctor NOW or go to the closest emergency department.

I have read the above Teleconsult Disclaimer*