Emergency Intake

Thank you for choosing 419 Dental for your dentistry needs. Please complete the form below, and a member of our team will reach out if we have any questions. If you have any questions, please feel free to contact us.

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Emergency Intake Form

Please fill out our emergency intake form in its entirety to ensure we can provide you with the best possible care.

Note: Any fields with * are required.

Today's Date *

Patient Name *

First

Last

Birthdate *

Phone Number *

Email Address *

Chief Complaint: *

Pain Level 1-10: *

Location of Pain: *

UL - UPPER LEFT
UA
UR - UPPER RIGHT
LL - LOWER LEFT
LA
LR - LOWER RIGHT

Select all that apply: *

Hot
Cold
Throbbing
Dull ache
Sharp pain
Bleeding gums
Lost filling
Trauma
Broken tooth
Other

Please specify. *

Previous Dentist *

Date of Last Visit *

Have you had dental X-rays done? *

When were your X-rays done? *

Insurance *

Insurance ID # *

General notes, if applicable:

Comment

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