EMERGENCY TELEPHONE SLIP
(erslip.doc)
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EMERGENCY TELEPHONE SLIP |
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Patient�s Name
________________________________________________________ |
Age ______ M or F |
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Parent�s Name (if
minor)
________________________________________________________________________ Home Phone #
____________________________
Work # ______________________________ Ext. _________ Referring
Doctor/Source
________________________________________________________________________ Address
_____________________________________________________________________________________ Current X-Rays
o Y
o
N
X-Rays Requested
o Y
o
N
Date ___________ |
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Mindset
:
o
Frightened
o
Hostile
o
Shy
o
Neutral
o
Pleasant
o
Other |
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Lost filling? |
Broken tooth? |
Toothache? |
Where? |
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Trauma? |
Swelling? |
Fever? |
How long? |
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Sensitive to
hot/cold? |
Pressure? |
Awake at night? |
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Pain Medication
_______________________________________________________________________________ |
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Payment Info: |
o Ins. |
o MC |
o CAP |
o PVT |
Fees Explained
o Yes
o
No
Estimate $ ______________
Given by _________
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Special Needs
________________________________________________________________________________ |
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New Patient
Practice Portfolio sent?
o
No
o
Yes
Medical History Form sent?
o
No
o
Yes |
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Call Taken by _____________________________ Comment
________________________________________
________________________________________
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SCHEDULED W/DR. ____________ |
APPOINTMENT
DATE ____________
TIME __________ |
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*Two copies of this form can be made on one letter size paper.
Samples from Standard Operating Procedures for All Dentists
(Contains over 470 pages + software)