*COMPLIMENTARY CONSULTATION

  Begin your path to a healthy smile today by completing our complimentary consultation form bellow. By providing us with the appropriate information we will better be able to diagnose your problem, advise you, and work together to solve it.  

Answer questions 6-21 with Yes or No.
(If Yes, give more details)

2- FULL NAME
1- EMAIL
3- PHONE
4- Describe your PAIN
5- SPECIFY THE LOCATION OF PAIN
8- Red, swollen or bleeding gums
6- Sensitive teeth or gums
7- Sensitive to heat
9- Sensitive to cold
10- Broken\chipped teeth
11- Night pain
12- Lost\broken filling(s)
13- Teeth grinding
14- Ringing in ear
15- Bad breath
16- Stained teeth
17- Blisters\sores in or around the mouth
18- Discomfort, clicking or popping in jaw
19- Are you on any long term medication?
20- Do you require any pre-medication?
21- Are you suffering any medical condition? (if yes, specify the condition)
Submit
Disclaimer
  
*The consultation process which includes and is limited to: filling out the consultation form, the preliminary diagnosis and pre-booking, and the advice given to the patient by the dentist, are the only parts of the treatment process that will be considered complimentary. Any work that is carried out by the dentist or any of the staff at Dentistry @ Brock Taunton, including the chair-side diagnosis, is not complimentary and the patient will need to provide payment for the treatment through the payment options discussed throughout our website.