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Virtual New Patient Exam
Let's get ready for your virtual exam appointment!
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* Indicates required question
STEP 1: Tell us about yourself
Patient Full Name
*
Your answer
Parent Full Name (MINOR)
Your answer
Responsible Party Phone Number
*
Your answer
Responsible Party E-Mail
*
Your answer
Patient Date of Birth
*
MM
/
DD
/
YYYY
Patient Dentist
*
Your answer
Has the patient been seen by Dr. Cooke before?
*
Yes
No
What is your chief concern? What would you like Dr. Cooke to evaluate?
*
Your answer
What days work best to schedule a virtual exam? (WE call YOU!)
*
Tuesday
Wednesday
Thursday
Friday
All of the above
Required
STEP 2: Take photos & upload them
Photo Tutorial
Example
Please submit your images to ONE of the following:
TEXT to (707)255-4400
EMAIL to info@cookeortho.com
STEP 3: Click submit
Submit
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