Back
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.
Do your gums bleed while brushing or flossing?
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?
Do you have any sores or lumps in or near your mouth?
Have you had any Head, Neck or Jaw injuries?
Have you ever experienced any of the following problems in your jaw:
Clicking
Pain (Joint, ear, side of face)
Difficulty in opening or closing
Difficulty in chewing
Do you clench or grind your teeth
Do you bite you lips or cheeks frequently?
Have you noticed any loosening of your teeth
Does food tend to become caught between your teeth
Have you ever had Periodontal Treatment (gums)
Ever worn a Bite Plate or other Appliance
Do you wear dentures or partials (If yes, Date and Placement below)
Date
Placement
Smile & Profile
Please Take The Above Photos
File Uploader
Upload
or drag files here
Overbite & Overjet
Please Take The Above Photos
Upload
or drag files here
Upper Arch & Lower Arch
Please Take The Above Photos
Upload
or drag files here
Right Bite & Left Bite
Please Take The Above Photos
Upload
or drag files here
First Name
Last Name
Date Of Birth
Phone
Email
Preferred Contact Method
Preferred Contact Time
Notes, Comments, or Questions
Back
Next
Back
Next
Submit
Done