OperaDDS - Form

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.

CORONAVIRUS DISEASE (COVID-19) SCREENING QUESTIONNAIRE

Have you traveled internationally, or to another State in the last 14 days?

Have you been in close contact with another person who has been diagnosed with/under investigation for COVID-19?

Do you have a cough, sore throat, fever, shortness of breath, or altered taste or smell?

Contact your primary physician or public health department as soon as possible to determine if you should be seen or tested.

Visit https://www.naccho.org/membership/lhd-directory for information on how to contact your local health department and https://www.cste.org/page/EpiOnCall for information on how to contact your state health department.

First Name

Last Name

Date Of Birth

Phone

Preferred Contact Method

Pharmacy Phone Number

Please list any medical concerns, conditions, medication, allergies you have.

Your description of your concerns. Please be VERY SPECIFIC, and answer all these questions. The location of it, when it happened, and what you think caused it. Is it painful, swollen, sharp, sensitive to hot, cold or chewing, broken, spontaneous, constant, or occasional, etc.

PLEASE TAKE PHOTO'S OF BROKEN OR PAINFUL TOOTH OR/AND SWELLING.

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We will be regularly reviewing these messages and will be getting back to you in a timely manner.