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Dental Emergency
In order to provide you a virtual consultation and assess your dental concerns, please submit your information below.
Your information will be securely sent back to our team to evaluate.
Please select area of the mouth
Are your teeth sensitive to HOT or COLD liquids/foods?
Are your teeth sensitive to SWEET or SOUR liquids/foods?
Do you feel pain to any of your teeth?
How painful (out of 10)?
Does it keep you up at night?
Do you have any sores or lumps in or near your mouth?
Have you had any Head, Neck or Jaw injuries?
Have you noticed any loosening of your teeth
Do you wear dentures or partials?
Any other information?
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Please Take The Above Photos
File Uploader
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Problem area
Please take as many photos as necessary to indicate the problem area
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First Name
Last Name
Date Of Birth
Phone
Email
Preferred Contact Method
Preferred Contact Time
Notes, Comments, or Questions
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