Charlotte Emergency Dental
Secure Patient Questionnaire
We are asking you to complete a series of documents that will allow our clinicians and office administrative staff to prepare for your visit.
To complete a document, simply fill out the fields with the requested information. Once you have completed a form, simply click the next button to proceed. Certain fields may be required prior to moving on. You will see these fields highlighted in red should you have missed any. Please don't use your browser's Back and Forward buttons. Use of these buttons may 'undo' your recent actions. If you are using an Android device, please avoid holding down while you scroll as this may refresh the page causing you to lose your information.
The information you will submit is secure and encrypted for your protection and is sent directly to our office. Thank you for helping us prepare for your quick and easy check-in.
Click Start to begin