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Emergency Dental Treatment Request
Tooth emergency? Fill out this form to request a dentist call.
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1
If this is a medical emergency please visit the nearest ER or contact 911
Click
next
to continue if this
does not apply
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2
Let's start first with your full
name
:
*
This field is required.
All information on this form is
private and confidential
First Name
Last Name
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3
Please provide your preferred
phone number
for contact:
*
This field is required.
If you do not have a phone number, please email us at clearwaterfamilydental@gmail.com
Please enter a valid phone number.
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4
Can we contact you via
text message
(SMS) to this number?
*
This field is required.
If your number is a land-line or not a mobile number, please select NO.
YES
NO
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5
Please briefly
summarize
your dental emergency:
*
This field is required.
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6
Are you an
existing patient
at Clearwater Family Dental?
*
This field is required.
YES
NO
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7
Who
is your current dentist/dental office?
We will typically send a report to the office outlining your problem after consultation
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8
If you are not a patient of our office, you will be
required
to fill out a medical history form before an appointment or prescriptions (if required) can be provided.
*
This field is required.
We are happy to assist with all medical emergencies; help does not require you leave your dental provider.
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9
Please
read
and confirm the following terms:
*
This field is required.
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10
Please
sign
to confirm the information above is accurate:
*
This field is required.
Clear
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