Consultation Payment & Patient Information

Thank you for scheduling a consultation with Survivor Smiles. Your consultation fee is $200 for either a virtual or in-person visit and includes a review of your medical and cancer treatment history, any necessary dental X-rays, and a 3D CBCT scan. Please complete the information below so our team can better understand your history, care team, and dental concerns before your consultation.

Name

Phone

Please describe your cancer journey, including the month/year of diagnosis, location/type of cancer, the name of the cancer center/hospital, and the type of cancer treatment you received (chemo? radiation? surgery? transplant? immunotherapy?).

Please tell us the name, phone number, and email addresses of your 2-3 main oncologists and/or doctors/nurses at the cancer center.

Please describe the most important dental concerns you have, i.e., 'I need dental implants but my dentist thinks this is too risky' or 'I have mouth complications because of my radiation history'.

Please upload the front AND back of BOTH your dental insurance and medical insurance cards. These can include your private dental/medical plans as well as Medicare.

By checking this box, you agree to receive SMS care related updates from Survivor Smiles at the phone number provided. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out or HELP for help. Consent is not a condition of purchase.

I have read and agree to the Privacy Policy and Terms & Conditions

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Our Offices

Find the Right Office
for Your Journey.

New York

Manhattan, NY

515 Madison Avenue
New York, NY 10022

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Plainville

Plainville, MA

6 Wilkins Drive Plainville, MA 02762

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Riverside

Riverside, RI

250 Wampanoag Trail Riverside, RI 02915

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Redding

Redding, CT

2 Long Ridge Road Redding, CT 06896

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Traveling for care?

We welcome patients from across the country. Our team can assist with coordinating appointments to maximize your time while visiting our Northeast offices.

Travel Information

Consultation Payment & Patient Information

Find the Right Officefor Your Journey.

New York

Plainville

Riverside

Redding

Traveling for care?

Find the Right Office
for Your Journey.