Patient Screening Form

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.  

Virtual Consultation

Due to COVID-19, the Kentucky Board of Dentistry recommends emergency procedures only. We would like to continue helping our patients via virtual consultations, minimizing the possibility of exposure. Please submit your info below to the secure office email and Dr. Kim will schedule you for Virtual Consultation through a video phone call ASAP.

***There is no confirmation screen after you submit. If the subject lines are blank, then the submission was successful! This transfer of information is not 100% HIPPA compliant

**Please use the flashlight on your camera when taking a picture inside your mouth. Take a close up picture of the problem tooth/area. If swelling is present, include a picture of your entire face as well.

-Consent-

I give my consent to receive dental diagnosis, education, and other dental-related services.  I understand that without X-ray, the diagnosis can be difficulty and limited for the dentist to provided to patients. I will receive instructions about the benefits and risks of the necessary procedures, and I will have the opportunity to discuss and approve the recommended treatment. I acknowledge that I have not received guarantees, warranties, or representations concerning the results of the treatment or procedures. I accept the responsibility to follow oral hygiene and post-op instructions, come to all the appointments on the proper day and time, provide accurate and updated health information, and alert this office of anything that may adversely affect the treatment. I have the right to withdraw this consent at any time. I will still be responsible for the unpaid balance and for any complication arising from the treatment interruption. I understand that video chat might have a risk of personal exposure information to others.