Emergency Dental Care Information Form
Please fill out the Emergency Dental Care Information form completely. The dentist on call will contact you as soon as possible.
Date Of Birth
When was the last time you visited Denzinger Family Dentistry?
Zip Code (Required for Prescriptions)
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.
or drag files here