Emergency Request

Name *

First Name

Last Name

Phone *

(###)

###

####

How should we contact you? *

Phone call

Text message

Email

Which clinic location would you like to visit? *

Calgary Clinic in Harvest Hills

Cochrane Clinic on Bow Street

Are you an existing patient at Harvest Dental Care? *

Yes

No, I'm new!

D3. Does your pain wake you or prevents you from sleeping? *

Yes

No

D4. Have you received any recent injury or trauma to your face, neck or mouth? *

Yes

No

D5. Have you developed any swellings or bumps inside or outside of your mouth since your discomfort began? *

Yes

No

D6. Please describe your intensity and type of pain? *

Cold

Hot

Biting

Throbbing

Aching

Dull

None