Old E-School Live Patient Application/Referral Form

Welcome to your Old E-School Live Patient Application/Referral Form

First & Last Name

Email

Phone Number

E-School LIVE takes place on September 21st and September 22nd, 2024

Are you available on September 21st AND September 22nd, 2024? We cannot guarantee which day or what time we can fit you in for an appointment, so you MUST be flexible and available at any time on both days in order to be eligible.

Yes, I am available and flexible on BOTH Saturday and Sunday

I am only available on ONE of the days

I am not available on either of the listed days

What is your location? All E-School LIVE sessions are located in Charlotte, North Carolina.

Patients are welcome from all over, but you must be willing to travel and pay for your own accommodations in Charlotte.

What dental work do you need performed? The endodontic focus is to treat conditions affecting the tooth pulp (the center of your teeth) and the tissue that surrounds the roots of your teeth.

Crowns & Fillings

Braces

Root Canal

Extractions

Cleanings

Who is your general dentist?

What are their contact details?

Please upload your referral slip (a photo is fine)

Drag and Drop File Here or Browse

Please upload an X-Ray File

Drag and Drop File Here or Browse

Not everyone who fills out this application is a candidate for treatment at E-School LIVE. Each application will be reviewed by a member of Dr. Chopra’s staff, and you will be reached out to if you have been selected for treatment.

By checking the box below you acknowledge this statement.

I understand that submitting this application does not guarantee I will be eligible for treatment at E-School LIVE.

I do not acknowledge the above statement.

Old E-School Live Patient Application/Referral Form

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