eConsultation Form

Faster, Personalized Estimates by using our eConsulation Form. Dr. Kamran Raja Will Call You to Discuss Your Specific Needs.

We Specialize in Oral & Implant Surgery

“I am excited to help you achieve your goals and improve your dental health. Please fill out this form if you are interested in a consultation. This will expedite the process and allow us to serve you better.” – Dr. Raja

Simple eConsultation Form

Patient Name*
First Last
Patient Date of Birth (DoB)*
Month
Day
Year
Patient Address (for Insurance Purposes)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How Did You Hear About Us?*
Mobile Phone*
Valid Email Address*
Procedure of Interest*
- Wisdom Teeth Extractions
- Dental Implants
- Oral Surgery
- Injectables & Fillers
- Other
Gender*
Goals for Surgery of Interest?*
None
Upload Photos for Dr. Kamran Raja to Review.*
Drop files here or

Accepted file types: jpg, gif, png, pdf, jpeg, pdf, Max. file size: 512 MB, Max. files: 4.
In order for us to provide the best consultation advice, Dr. Raja would like for you to upload Images of the Tooth or Teeth needing surgery. You can also upload a scanned version of the X-Rays from your dentist.
Disclaimer*
I agree to the disclaimer policy.
Disclaimer: An eConsult is not a substitute for an in-person consultation if we proceed to schedule surgery.