Triage Form

Dental Emergency Triage Form
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Current Patient or New? *

Current New
Changes in Medical History (existing patients only) *

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)
If new patient, who referred you?
Preferred Pharmacy *
Pharmacy Phone Number *

Area Code Phone Number
Photo of Child's Face (for identification purposes) *

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Cancel 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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Cancel 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.

Clear
Should be Empty:

Dental Emergency Triage Form