Dental Emergency
Full Name
Date:
/
Month
/
Day
Year
Date
Phone Number
Tribe:
Date of Birth
-
Month
-
Day
Year
Date
Age
Address
Address
Street Address Line 2
City, State, Zip
State / Province
Postal / Zip Code
Please indicate if you have any of the following insurance.
Private Insurance
Medicaid
Medicare
No Insurance
Name of Private Insurance
Are you an established patient?
Yes
No
How long has it been since your last dental visit?
Which tooth is it?
Upper
Lower
Right
Left
Front
Back
1/2 Way Back
Can't Tell
Please indicate your pain level.
Level 1 - Swelling or bruising.
Level 2 - Pain of recent duration (1-2 days to hot/cold/biting pressure).
Level 3 - Chipped tooth, lost restoration causing no pain, broken tooth.
Does the tooth feel loose?
Yes
No
Is there a filling in the tooth?
Yes
No
Is the filling:
Recent
Old
Broken
Lost
How long has it been hurting?
Are you taking any medication?
Please Select
Yes
No
What medication?
Reason for visit today (Please be as specific as possible):
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