[Secure Form] Online Video Consultation Form

Online Video Consultation Request Form

Complete The Form Below To Request An Appointment

To schedule your online video consultation with one of our surgeons, please complete the form. Once completed, our staff will follow up with instructions and an appointment time that works for you. If you have any questions, please contact our office at (205) 870-5834.

* Required Fields

Full Name

Phone Number

Email Address

Date of Birth

Procedure

Other Procedure

Medical and/or Dental History

Photos

In order for our doctors to get a better understanding of your condition and accurately determine the appropriate treatment, please take at least two pictures that clearly represent your areas of concern.

Upload File(s)

Click Here to Upload

Questions or Comments For Doctors

HIPAA Privacy Policy

Our office is dedicated to protecting the rights of our patients and the confidential information entrusted to us. We are committed to developing technology that gives you the most powerful and safe online experience. The form information provided is stored securely as required by the Health Insurance Portability and Accountability Act (HIPAA) and the state of Alabama and will only be seen by the doctors and staff at Roden Oral, Facial, and Dental Implant Surgery. Learn more about our HIPAA Privacy Policy.

By checking this box, you authorize and voluntarily consent to share your personal information for use in treatment, and you acknowledge, understand, and agree with the contents in our HIPAA Privacy Policy.