After Hours Dental Emergency *Current Patients/Families Only*
*This form will only be received after business hours.* * During business hours, please call one of our offices for assistance.
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Current Family or New to our practice?
*
Current
New (Do not complete this form. Call our office on the next business day.)
Changes in Medical History
*
No
Yes
If changes to Medical History, please specify
Parent Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Dental Concern
*
Trauma
Swelling
Pain
Description of Emergency
*
Pediatrician/Physician (please include their phone number)
Preferred Pharmacy
*
Pharmacy Phone Number
*
-
Area Code
Phone Number
Photo of Child's Face (for identification purposes)
*
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of
Photo of Dental Concern
*
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Please limit image size to 1MB
Cancel
of
Photo of Dental Concern
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of
I agree to the dentist billing my insurance for the tele-dentistry consultation and I give consent for them to view and/or consult another medical/dental provider for diagnosis and treatment options.
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