Emergency Dental Treatment Request

1

If this is a medical emergency please visit the nearest ER or contact 911Click next to continue if this does not apply

2

Let's start first with your full name:* This field is required.All information on this form is private and confidential

First Name

Last Name

3

Please provide your preferred phone number for contact:* This field is required.If you do not have a phone number, please email us at clearwaterfamilydental@gmail.com

Please enter a valid phone number.

4

Can we contact you via text message (SMS) to this number?* This field is required.If your number is a land-line or not a mobile number, please select NO.

YESNO

5

Please briefly summarize your dental emergency:* This field is required.

6

Are you an existing patient at Clearwater Family Dental?* This field is required.

YESNO

7

Who is your current dentist/dental office?We will typically send a report to the office outlining your problem after consultation

8

If you are not a patient of our office, you will be required to fill out a medical history form before an appointment or prescriptions (if required) can be provided.* This field is required.We are happy to assist with all medical emergencies; help does not require you leave your dental provider.

9

Please read and confirm the following terms:* This field is required.

10

Please sign to confirm the information above is accurate:* This field is required.