COVID-19 Tele-Dentistry Services

The COVID-19 national emergency has curtailed our ability to treat dental patients in person. We are, however, able to provide a broad range of Internet-accessible dental evaluation, consultation and remote treatment services! These online Tele-Dentistry services are available today for you, for scheduled or emergency appointments.

Our dentists at North Potomac Smiles are available to help. Please complete the form for immediate assistance.

Schedule Your Virtual Consultation

Your Name(*)

Full name is required

Your Email(*)

Please specify your email address.

Phone(*)

Contact phone number required

City(*) City required

State(*) State required

Zip(*) ZIP code required

Description of Problem(*)

Please provide some information about your dental concerns

Age of Patient(*)

Age required

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Has your dental insurance changed since your last visit with us?

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NEW PATIENT REGISTRATION

Do you have dental insurance?

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Dental Insurance Name / Subscribers ID (*)

Dental Insurance information required

Name of Pharmacy(*)

Name of Pharmacy required

Address of Pharmacy(*)

Address of Pharmacy required

Pharmacy Phone(*)

Contact phone number required

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 North Potomac Smiles, 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. Your policy acknowledgement consent is required

Your insurance will be billed for this consult. Anything not covered by insurance will be the patient's responsibility. The consult charge is $75.

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COVID-19 Tele-Dentistry Services

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