Name

First Name

Last Name

Phone *

(###)

###

####

Are you a current patient of record? *

Yes

No

If you are not a patient of record, are you interested in:

Establishing care

Problem-focused exam

Both

New and current patients with problem-focused needs related to toothaches, fractured teeth, or swelling:

Please select all that apply.

Upper

Lower

Generalized

Front (incisors/cuspids)

Back (molar/premolar area)

Temperature-sensitive

Dull ache

Pain on biting or chewing

Bleeding