Emergency Case

Emergency Case

Emergency dental care may be needed if you have had a blow to the face, lost a filling, or cracked a tooth.

• 416-843-4284
• info@eastondental.ca

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Name *

First

Last

Email *

Phone Number *

Age

National ID / Health Card Number

following? Level medication

Type of Emergency Severe toothacheBroken or cracked toothSwelling or abscessGum or tooth bleedingDental trauma (e.g., hit/fall)Loose tooth or dental implantIssue with crown / bridge / veneerOther

Please select the main issue

When did the issue start?

Pain Level (0 to 10)

Have you taken any medication for this?

If yes, which one?

Preferred Appointment Time *

• As soon as possible
• Anytime today
• Tomorrow
• Mornings only
• Afternoons only

Do you have any of the following? *

• Diabetes
• High blood pressure
• Pregnancy
• Allergy to medications
• Heart conditions
• Other
• None

Submit Emergency Request