Online Dental Problem Form
This form is intended for when Borrowash Dental Centre is closed and you are able to wait until the dental practice reopens. If you are unable to wait until the practice is next open, please telephone the practice where the answer machine will guide you further. Please provide as much information as possible in the spaces below.
Are you a new or existing patient of Borrowash Dental Centre? *
Have you been seen at Borrowash Dental Centre for a dental appointment within the last 2 years? *
What dental problem do you have? Which tooth is causing the problem? Which side of the mouth? *
Have you suffered any trauma to the teeth? *
Are you suffering any prolonged bleeding following a dental extraction? *
Are you aware of having any treatment previously carried out with the problem tooth? *
Is there any pain or discomfort? If so, how long have you been in pain? *
Is there pain to hot or cold temperatures?
Is the tooth painful to bite on?
Clear selection
Are you needing to take painkillers or any medication for the pain? If so, please state what type of medication and what dosage.
Is there any swelling of the face? *
Is there any swelling of the gum? *
Is the dental issue affecting your sleep? *
Is it tender to bite or tender to touch the area where the dental issue is occurring? *
Is there any additional information you wish to provide?
What is your name? *
What is your telephone contact number which you give us permission to contact you? *
What is your email address?
Do you give us permission to contact you by email?
Clear selection
Please state today's date. For example 24th May 2020 *
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