After Hours Dental Emergency *Current Patients/Families Only*
*This form will only be received after business hours until 9 p.m.* During business hours, please call one of our offices for assistance. After 9 p.m., please seek care at your nearest emergency room.
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Current Family or New to our practice?
*
Current (Your family has been seen in our office within the last year)
New Patients or families we have not seen in our office in over a year (Do not complete this form. Call our office on the next business day)
Changes in Medical History
*
No
Yes
If changes to Medical History, please specify
Parent Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Dental Concern
*
Trauma
Swelling
Pain
Other
Description of Emergency
*
Pediatrician/Physician (please include their phone number)
Preferred Pharmacy
*
Pharmacy Phone Number
*
-
Area Code
Phone Number
Photo of Child's Face (for identification purposes)
*
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Photo of Dental Concern
*
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of
Photo of Dental Concern
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of
I consent to pay a $85 consultation charge for a teledentistry encounter. Furthermore, I authorize the dentist to review and consult with other medical or dental professionals for diagnosis and treatment options. Charges will be submitted to the insurance on record or billed directly to me.
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