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Dental Emergency Questionnaire
It is always recommended that you call us at 952-927-6477 to let us know of your dental emergency. All messages will be answered as soon as possible. You are not guaranteed an appointment time and will be scheduled as our schedule will allow. Work is not guaranteed to be completed and your appointment may be deemed an emergency consultation only. You may or may not be referred to a specialist.
Choose one:
First Name
Last Name
Date Of Birth
In order to provide you a consultation and assess your dental concerns, please submit your information below.
Do you have any pain in your teeth?
Drop-down
Are you sensitive to HOT and/or COLD temperatures?
If Yes, choose one:
Do you have any sores or lumps in or near your mouth?
Checkbox
Are any of your teeth chipped, cracked or broken?
Checkbox
Have you had any injuries to your head, neck or jaw?
Please write a description of your dental emergency below
Upper Arch & Lower Arch
Please take or attach photos of the dental issue(s) as seen above, with as much light as possible:
Upload
or drag files here
Phone
Email
Choose all that apply:
Choose all that apply:
Notes, Comments, or Questions
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