Welcome to your E-School LIVE Patient Application/Referral Form

First & Last Name
Email
Phone Number
E-School LIVE takes place on April 27th and April 28th, 2024

Are you available on April 27th AND April 28th, 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.

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.

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.