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? *

I am a new patient

I am an existing patient

Have you been seen at Borrowash Dental Centre for a dental appointment within the last 2 years? *

Yes

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? *

Minor dental trauma including a tooth fracture or a baby tooth being knocked out..

A permanent tooth has been knocked out completely

Severe trauma

Are you suffering any prolonged bleeding following a dental extraction? *

Yes

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?

Yes

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? *

Yes

Is there any swelling of the gum? *

Yes

Is the dental issue affecting your sleep? *

Yes

Is it tender to bite or tender to touch the area where the dental issue is occurring? *

Yes

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?

Yes

Clear selection

Please state today's date. For example 24th May 2020 *

Submit

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