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.
Are your teeth sensitive to HOT or COLD liquids/foods?
Do you feel pain to any of your teeth?
Do you have any swelling?
Do you have any sores or lumps in or near your mouth?
Have you ever experienced any of the following problems in your jaw:
Clicking
Pain (Joint, ear, side of face)
Difficulty in opening or closing
Do you clench or grind your teeth
First Name
Last Name
Date Of Birth
Phone:
Email:
Pharmacy Name:
Pharmacy Number:
Please list any allergies:
Notes, Comments, or Questions
Can you pinpoint a certain area/tooth? Upper/Lower Left/Right Back/Side or Front?
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