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 (mm/dd/yyyy) *

Email *

Phone *

Address *

City *

State *

Postal code *

Preferred Method of Contact *

Call

Text

Email

Is the patient a minor? *

Is the patient a minor?

Yes
No
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If yes, please provide the Parent or Guardian's Full Name and Date of Birth.

Appointment Information

What type of appointment do you need? *

Root Canal

Retreatment (of Previously Treated Root Canal)

Evaluation

Unsure

Preferred Appointment Day (select all that apply) *

Monday

Tuesday

Wednesday

Thursday

Any

Preferred Appointment Time (select all that apply) *

Morning

Midday

Afternoon

Any

Background Information

Name of Referring Doctor *

Is your dental problem the result of an accident? *

Is your dental problem the result of an accident?

Yes
No
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If yes, please describe the accident with the date it occurred.

Is the tooth sensitive to: *

Hot

Cold

Sweets

Biting

None of the Above

If sensitivity is present, when did the sensitivity start?

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