For Emergency Care @ Town & Country Dental of Oak Park

5-Star Emergency Care at T&C Dental of Oak Park

We are available to help you with your emergency. We will treat you like family so we take great pride in providing urgent, comfortable emergency care. Complete this form to initiate a call back from Dr. Wegner.

What is your pain level on a scale of 1 to 10?*

	1	2	3	4	5	6	7	8	9	10

1 is Slight Discomfort, 10 is Unbearable Pain

When was your last visit to a dentist?*

1-4 weeks1-12 monts1-2 years3-5 yearsMore than 5 years
Briefly describe your emergency:*
Overall Health of Your Teeth (select one):*

ExcellentGoodFairPoor
Overall Health of Gums (select one):*

ExcellentGoodFairPoor
Are you happy with your smile appearance?*

YesYes, but it could be improvedNo, I am self-conscious about my smile
Our team is committed to treating you
like family!

Be sure to let a staff member know if there is anything we can do to improve your experiences in our office!
Contact Information:
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Should be Empty:

5-Star Emergency Care at T&C Dental of Oak Park