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PERSONAL DETAILS

Your personal details. Please review them and make any necessary adjustments.

Title

First Name

Last Name

Preferred Name

Gender

Date of Birth

Address

Address 2

Province/State

City

Postal /Zip Code

Home #

Work #

Ext.

Mobile #

Other #

Preferred Phone

Email

Contact Method

Employer/School

Occupation

Are you available for short notice appointments? (Check if available)

How did you hear about us (Internet, Walk-In, Referred)? If referred, please provide name of person/business.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Relation

Emergency Phone #

Date of Call

What area is causing pain/ discomfort?

How long have you had this pain/ discomfort?

Are you taking anything for the pain?

Yes

No

If so, what medication are you taking and for how long have you been taking it?

Has the medication aleviated some of the pain/discomfort

Yes

No

Pain Characteristics

Out of 10, what would you rate the pain? (10 being the worst)

Can you describe the pain? (sharp, throbbing,constant,intermitten)

Is your pain getting worse?

Yes

No

Is there any noticeable swelling in your mouth, face, tongue or neck?

Do you have any signs of infection such as fever, redness, or discharge of pus?

Do you have a dental abscess or any swelling that feels warm to touch?

Is there any bleeding in your mouth or gums? If so, how long has it been going on for?

Are you experiencing a bad taste in your mouth or bad breath that doesn't go away with brushing

Yes

No

Have you recently experienced any trauma/ injury to your teeth, mouth or jaw? (e.g., accident, fall, sports injury?

Is there any visible damage such as broken, chipped or knocked-out teeth?

For Trauma patients:
1.Tetanus shots- must be up to date for patient. If not- call family doctor as you need this prior to being seem here. Inform DDS of what is happening with this patient to make proper decision.
2.If tooth is still present, please bring it to the appointment- keep it in milk or saliva.

Is this causing significant discomfort or affecting your ability to eat or speak?

Yes

No

Overall Health Concerns

Do you have any underlying health conditions (e.g., diabetes, heart disease) that might be affected by your dental issue?

Are you currently undergoing any medical treatments (e.g.,chemotherapy) that might complicate a dental issue?

Appoinment Booking

Based on the answers to these questions, the admin team can determine the urgency of the situation.
If the patient is experiencing severe pain, swelling, infection, uncontrollable bleeding, or trauma, they should be scheduled for an immediate appointment. For less urgent issues, the patient may be scheduled for the next available slot within a reasonable time frame.

Date of the emergency appointment if booked?

Was estimate for visit given to the patient? (Exam + PA)

Yes

No

Signature of the Patient or Admin team representive that assisted patient and booked appointment: