Our dental care team will contact you within 1 business day after submitting this form. If you need immediate assistance, please call our office directly at (850) 696-0820

Patient Information

First Name *

Last Name *

Date of birth *

Email *

Phone *

Address *

City *

State *

Postal code *

Preferred Method of Contact *

Call

Text

Email

Is the patient a minor? *

Is the patient a minor?

If yes, please provide the Parent or Guardian's Full Name and Date of Birth.

What type of appointment do you need? *

Root Canal

Retreatment (of Previously Treated Root Canal)

Evaluation

Unsure

Preferred Appointment Day *

Monday

Tuesday

Wednesday

Thursday

Preferred Appointment Time *

Morning

Midday

Afternoon

Name of Referring Doctor *

Is your dental problem the result of an accident? *

Is your dental problem the result of an accident?

If yes, please describe the accident with the date it occurred.

Is the tooth sensitive to: *

Hot

Cold

Sweets

Biting

When did the sensitivity start? *

Any other questions you would like our team to address during your initial phone call? *