Telephone Call Form
Brent C. Caple, D.D.S. Pediatric Dentistry | 5204 Village Parkway, Suite 14, Rogers AR 72758
Patient Information
Patient Name
First Name
Last Name
Chart #
Date of Birth
-
Month
-
Day
Year
Date
Age
Parent / Guardian Name:
Relationship to Patient
Call Back Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Call
Select Reason
Trauma
Pain
Swelling
Filling Out / Crown Off
Cavity
Baby Tooth Not Out
Referred NP for TX
2nd Opinion
NP over 10 years
Other
Details
What Happened:
When Did It Happen?
Where?
Upper
Lower
Front
Back
Right
Left
How Often Does It Hurt?
On & Off
Constantly
When Eating
Keeps Awake at Night
Other
Is it sensitive?
Yes
No
Type of Sensitivity:
Hot/Cold
When Eating
Other
Fever?
Yes
No
Temperature?
Pain Medication?
Yes
No
Medication:
Amount:
When:
Email Picture?
Yes
No
How soon are you able to get here if Dr. Caple can see you today?
I will talk with Dr. Caple and call you back by:
2nd Opinion
Referring Dentist Name:
Date of Last NP or Periodic Exam:
-
Month
-
Day
Year
Date
Date of Last Cleaning:
-
Month
-
Day
Year
Date
Date of Last X-Rays:
-
Month
-
Day
Year
Date
Comments
Comments:
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