Emergency Dentistry

In the case of a dental emergency, the following information will help us identify the issue before arriving in the office. 

your Chief Complaint:

  1. Broken Tooth  

  2. Broken Filling

  3. Loose Tooth 

  4. Loose Crown / Bridge / Implant

  5. Broken Denture or Partial 

  6. Denture / Partial Adjustment

  7. Gum Problem  

  8. Toothache

  9. Loose / Sharp Ortho Wire  

  10. Bracket Off 

  11. Band Off 

  12. OTHER: __________________________

  13. Crown Off:   Yes   /   No       If Yes, is the tooth broken off in the crown:   Yes   /   No

describe your Discomfort:

  1. Throbbing:   Yes   /   No

  2. Sensitive to hot:   Yes   /   No

  3. Sensitive to cold:   Yes   /   No

  4. Sensitive to biting:   Yes   /   No

  5. Lingering sensitivity:   Yes   /   No

location of your Discomfort: 

UPPER     /     LOWER     /     RIGHT     /     LEFT     /     FRONT     /     BACK

Is there swelling?   Yes   /   No

How long has the tooth been bothering you? ________________

Does it keep you up at night?   Yes   /   No

Have you had any recent treatment on this tooth?   Yes   /   No

TORONTO, ONTARIO

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© 2016 by Dr Brian Friedman.