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:

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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

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describe your Discomfort:

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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

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location of your Discomfort: 

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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

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TORONTO, ONTARIO