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Emergency Dental Care Information Form
Please fill out this Emergency Dental Care Information form completely along with any other forms in this packet. The dentist on call will contact you as soon as possible.
If all forms in this packet are not completed, the on-call dentist will not get a notification that you need to talk to them.
Date
First Name
Last Name
Email
Phone
Date Of Birth
When was the last time you visited Denzinger Family Dentistry?
Address
City
State
Zip Code
Please describe your situation:
Do you have a history in the problem area?
Are you having pain in the problem area?
What is your pain level?
Is the pain getting better, staying the same or getting worse?
Are you taking any medication to relieve the pain?
What medicines and what dosage?
If you want to send photos, please upload them here.
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