Patient Symptom Confirmation Checklist

Patient No: SP-

Please answer each question honestly to help us properly assess your condition and provide the most appropriate recommendation.

1. Are you experiencing pain or sensitivity/discomfort?
Yes
No

2. Do you have swelling or bleeding gums?
Yes
No

3. Do you have difficulty swallowing?
Yes
No

4. Do you have have fever or signs of infection?
Yes
No

5. Have you had recent dental trauma?
Yes
No

If you answer “Yes” to any of the above, kindly specify when the symptom occurred or how long it has been present:

Important! By clicking the checkbox, I represent and warrant that I have read and fully understood all the above statement, including the Data Privacy Policies of the clinic and my employer.