Please fill out the form below and upload them in the available fields.

Use your phone or a digital camera to take the images below. It may help to have a friend or family member take the pictures so you can move your cheeks out of the way to get the best shot. Try and get as close as you can while still showing the entire mouth in focus.

Upload Your Images Here

Note that the form on our website is not able to accept large file sizes, so please be sure to upload photos that are 4mb or less.

Max. file size: 4 MB.
Max. file size: 4 MB.
Max. file size: 4 MB.
Max. file size: 4 MB.
Max. file size: 4 MB.


I hereby authorize and request, Dr. Himelhoch, to provide to me dental professional services using electronic and/or digital communications, or teledentistry.
I acknowledge the following:
a) The potential for breach of confidentiality, or inadvertent access, of protected health information.
using electronic and digital communication in the provision of care; and
b) The potential disruption of electronic and digital communication in the use of teledentistry.
I permit Dr. Himelhoch to use teledentistry services to provide care for:

  • Braces
  • Clear Aligners
  • Pediatric Dentistry
  • Retainers

I acknowledge that it is Dr. Himelhoch’s role to determine whether the condition being
diagnosed or treated is appropriate for a teledentistry encounter.

Risks, benefits and alternatives. The benefits of teledentistry include having access to a dentist and additional dental information without having to travel to a dental office or clinic. A potential risk of teledentistry is that a face-to-face consultation with a dentist may still be necessary after the teledentistry appointment. This could be because of my specific medical or dental condition or for other reasons.

Recommendations will be made to me about my future dental care after the teledentistry consultation.
These could include recommendations about whether or not to see a dentist, specialist, or oral surgeon in a dental office or dental clinic. A visit to a dental office may be needed in the future even if it is not recommended now. The recommendations may change if more information about my dental needs becomes known. The alternative to teledentistry consultation is a face-to-face visit with a dentist.

I may choose not to participate in a teledentistry consultation at any time before and/or during the consultation. If I decide not to participate, it will not affect my right to future care or treatment. I have the option to seek dental consultation or treatment in a dental office at any time before or after the teledentistry consultation.

Dr. Himelhoch will provide you with some preliminary treatment options through a virtual consultation. Dr. Himelhoch will need to perform an in-office exam to give an exact diagnosis as soon as possible. When you send us an email through our website, the information sent is not encrypted. That means a third party may be able to access the information and read it since it is transmitted over the Internet. If you receive an email, someone may be able to access your email account and read it.

  • HIPAA stands for the Health Insurance Portability and Accountability Act
  • HIPAA was passed by the U.S. government in 1996 in order to establish privacy and security protections for health information
  • Information stored on our computers is encrypted.
  • Most popular email services (ex. Hotmail®, Gmail®, Yahoo®) do not utilize encrypted email.
  • Email is a very popular and convenient way to communicate for a lot of people, so in their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA.
  • The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email.
  • For more information visit



Tuesday 8:30 am – 5:00 pm
Thursday 8:30 am – 5:00 pm
Friday 8:30 am – 4:00 pm
Saturday* 8:00 am – 1:00 pm
* Two Saturdays per month