PatientPop
Emergency Triage FormPatient’s Name:_______________________Intake Person’s Name:__________________Are you in pain today? __________________What is your pain level: Circle one: 1 2 3 4 5 6 7 8 9 10Where is your pain?(ex. Upper right side, tooth #)____________________How long have you been in pain?________________________________Has this tooth had previous treatment?_________ If yes, when and what?_____________________________________Is this tooth treatment planned for any treatment?___________________ If yes, would you like treatment completed on today?_____________________________________________Method of Payment:__________________________ ................
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