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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Broken Tooth
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Broken Filling
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Loose Tooth
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Loose Crown / Bridge / Implant
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Broken Denture or Partial
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Denture / Partial Adjustment
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Gum Problem
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Toothache
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Loose / Sharp Ortho Wire
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Bracket Off
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Band Off
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OTHER: __________________________
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Crown Off: Yes / No If Yes, is the tooth broken off in the crown: Yes / No
describe your Discomfort:
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Throbbing: Yes / No
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Sensitive to hot: Yes / No
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Sensitive to cold: Yes / No
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Sensitive to biting: Yes / No
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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