Ask the Dentist Form

Ask the Dentist
All information that you provide remains completely confidential. Please refer to our privacy policy
Fields marked with an asterisk (*) must be completed to enable us to process the form.
I need to know if you are experiencing pain:*
Yes, I am experiencing pain
No, I have no pain
If you are experiencing pain, complete sections A and B
If you have no pain & are only making a general enquiry, to go to section B
SECTION A - COMPLETE THIS SECTION ONLY IF YOU ARE EXPERIENCING PAIN
Identify the location of the pain:
Upper left
Upper right
Lower left
Lower right
In the gum
In the jaw joint
Identify the nature of the pain:
Is the pain worse with?
SECTION B - GENERAL ENQUIRY
Which of the following best describes the nature of your enquiry?
Are you an existing patient?*
Yes
No
* Will you be making an appointment after completing this form?*
Yes
No
Unsure
Already made an Appointment
Please provide the following information so that we can respond to your enquiry:
First name*
Last Name*
Preferred phone*
Email*
* Would you like us to contact you by telephone?
Yes, you may telephone me
I prefer an email response