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Comfort Form
The form is designed for your convenience to potentially save you a visit into the office by allowing us to assess the issue and make recommendations. It also allows us to evaluate the issue so if it requires an office visit, we are able to prepare for how we can best help you when you come in. Please submit your information below.

Your info will be securely sent back to our team to evaluate. We hope to gather enough information to recommend some techniques from home or help us setup and prepare for an office visit.
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Patient First Name *
Patient Last Name *
Name of person filling out form, if different from patient
Patient DOB *
MM
/
DD
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YYYY
Mobile Number *
Preferred Contact Method *
Please rate your level of discomfort (0 is no discomfort and 10 is absolutely unbearable) *
Please describe as detailed as possible what is causing discomfort for Dr. Haverkos or a team member to review. Please include what area of the mouth it is located (ie upper right towards the back, upper right towards the front, etc) If you have a loose or broken fixed retainer, please let us know if you still have your removable retainer or not and if you are able to still wear it. *
A team member will respond within 24 hours or the next business day. If you cannot wait due to severe pain, swelling, or trauma, please call or text the main office number during business hours 513-481-8000 or the on-call number at 513-549-1881 after business hours and someone will respond as soon as they can. *
Required

Please text a picture or a short video from your phone to 513-481-8000.  Please use your fingers or a spoon to retract the lip and soft tissue in order to give a full view of the issue. *
Required
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