DrBunn.com - Dental Problem Report

DrBunn.com Steven T Bunn, DDS promoting dentistry with caring, comfort and quality

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Dental Problem Report

-- responses only to existing patients of Dr. Bunn --

Responses are intended to be timely; however, Dr. Bunn is not liable for the lack of response or delayed responses.

Topics appropriate for email vs. a face-to-face visit include those subjects which are not time sensitive or emergency situations. If you are faced with an emergency, make an appointment with your appropriate healthcare provider or go directly to the emergency room instead of asking for advice via web / email.

It can sometimes be difficult to diagnose a problem without more specific information from you. An excellent way to use this report is to print the page once filled out.

None of the blanks are required to be filled-in, but the more information you provide the easier it is to help you.

*First Name*
*Last Name*
*Middle Initial*
*Date of Birth*
*Gender*	Male Female
*Title*
*Street Address 1, Home*
*Street Address 2, Home*
*City*
*State*
*Zip Code*
*Work Phone*
*Home Phone*
*FAX*
*E-mail*


Problem / Concern Description
*What Is Involved*

*Problem / Concern*

*How Does It Feel*	Does anything make it feel better, and if so, what? Does anything make it feel worse, and if so, what?

*Sensitive To*	touch air sweets

*How Often*

When

Intensity

How Long Has It Occurred

Area/Location	upper lower left right which tooth, or next to which tooth area

*Action(s) Taken / Other*	What action/medication has been taken? Was there any recent dental treatment related to the current condition, and if so what and when?

*Further Description*

Please only submit this from existing patients.
Feel free to print the report for your own use.

Please wait once you click on "Send".
When transmitted successfully you will see a "Thank You".

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web site content, design, maintenance, and funding by Steven T Bunn, DDS
no commercial sponsorship or advertising

Disclaimer:
The materials on my web site are not intended as a substitute for professional dental / medical advice, and accordingly you should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. I may change or update information contained on this web site without notice to represent recent developments in health care.

It is important to understand the risks of communicating with you electronically since information will be transmitted over the public Internet, such as a third-party intercepting a message, or the message not getting through. Responses are intended to be timely; however, Dr. Steve Bunn is not liable for the lack of response or delayed responses.