*Name

*Email

*Phone

*Location of Problem (click all that applies)

Front Teeth
Back Teeth
Upper Left
Upper Right
Lower Left
Lower Right
Left side of Face/Jaw
Right side of Face/Jaw

*Nature of Discomfort (click all that applies)

Sensitivity to Cold
Sensitivity to Hot
Sensitivity to Chewing
Swelling present
Taking painkillers
Bleeding present
Aching/Throbbing Constantly (more than 1 hour)
Disturbing sleep

Further Information

Your Availability over next 3 days

(e.g. Mon 9am-1pm Tues 1pm-5pm)

Any acute/chronic medical conditions: