Free Virtual Emergency Dental Care Consult Form

You can avoid coming into the office for emergency dental care and dental pain. We're offering a FREE online emergency dental care consultation below (via this secure, HIPAA compliant webpage), so you can get the help you need now.

Are you an existing patient of Moorehead Family Dentistry?

Yes

No, but I have a referral to your office

No, and I do not have a referral

Patient Name

Email Address

Phone Number

Current pain level out of 10 Select level...1=low, 10=excruciating No Current Pain 1 2 3 4 5 6 7 8 9 10

Where is the pain? (you can select more than one) Whole Mouth Top Left Top Right Bottom Left Bottom Right No Pain Currently

Do you have an infection? (swelling, pus, bad taste in mouth) Yes No I don't know

Is there pain when you bite down? Yes No

The location you wish to visit for treatment Select location... Blue Ash Batavia Lebanon

Name of dental insurance company, if using dental insurance (type 'none' if this doesn't apply)

Photo of trouble area #1 (if you have a current xray, take a picture of that!)

Photo of trouble area #2 (optional)

Share any additional details or concerns about your issue

We have a different form created specifically for you! Go to forms.mooreheaddentistry.com/referral and fill out that form, which will allow you to be seen as soon as we reopen. If you have current dental pain, make note of that in the questions/concerns section at the bottom of that form.

Will you be using dental insurance? Select from list... Medicaid Insurance (Caresouce, Molina, DentaQuest, etc.) Employer Provided Plan (Delta Dental, Cigna, MetLife, etc.) No Insurance Other

Unfortunately we are not able to schedule new patients with Medicaid insurance unless you have a referral (our standard operating policies). 

Patient Name

Email Address

Phone Number

Name of dental insurance company

Current pain level out of 10 Select level...1=low, 10=excruciating No Current Pain 1 2 3 4 5 6 7 8 9 10

Where is the pain? (you can select more than one) Whole Mouth Top Left Top Right Bottom Left Bottom Right No Pain Currently

Do you have an infection? (swelling, pus, bad taste in mouth) Yes No I don't know

Is there pain when you bite down? Yes No

The location you wish to visit for treatment Select location... Blue Ash Batavia Lebanon

Do you consider Moorehead Family Dentistry your current dental home? Yes No

Photo of trouble area #1 (if you have a current xray, take a picture of that!)

Photo of trouble area #2 (optional)

Share any additional details or concerns about your issue

Photo Consent

I consent to the photo(s) being used for the following: Dental Records • Dental Research • Dental Education including lectures, seminars, demonstrations, professional publications such as journals or books • Marketing material, including websites and printed materials, patient education. I further understand that if the photographs and/or videos are used, my name or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these photographs.

COVID-19 Screening

Have you you or anyone in your household had a fever in the last week? Yes No

Have you you or anyone in your household displayed the symptoms of COVID-19 including fever, cough, or shortness of breath in the last 10 days? Yes No

Verify Submission

submit

Thank you for submitting your online consult.

We have received your submission and the staff will review your info and we will reach out to you with the best next steps within 1 business day.