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Emergency Form
Emergency Form
adminamir
2020-04-17T18:11:04+00:00
Dental Emergency Online Consultation
Dental Emergency Online Consultation Form
RM_Stats
Full Name
Date of Birth
Phone Number
Email
City
Do you have any Medical Conditions
Yes
No
Are you taking any Medications
Yes
No
(if yes please list)
Do you have any allergies
Yes
No
(if yes please list)
Which area of the mouth are you experiencing symptoms with
Teeth/Gums in Upper Jaw (Maxilla)
Teeth/Gums in Lower Jaw (Mandible)
Check/ Tongue/ Palate/ Floor of mouth
When did you first start having symptoms?
Severity of the pain
Mild
Moderate
Severe
Extremely Severe
Pain History (Please Check all that applies)
Spontaneous Pain
Continuous Pain
Intermittent Pain
Dull Ache
Sharp Pain
Pain to Hot/Cold
Pain to Chewing
Pain to Touch
Do you have any swelling in your Mouth/ Gums
Yes
No
Do you have a swelling on your face
Yes
No
Do You have any bitter and/or unpleasant taste in your mouth
Yes
No
Are you currently experiencing any Fever and/or Chills
Yes
No
Do you have any restrictions in mouth opening
Yes
No
Are you currently experiencing any difficulty breathing?
Yes
No
Are you currently experiencing any pain on Swallowing and/or Breathing
Yes
No
Additional Information: Please provide us with any additional information that you feel is relevant regarding your dental emergency? (if you are suffering from dental trauma please provide more information about the trauma):
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