 419-445-8176 … archboldfamilydental@gmail.com… … …

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Emergency Intake

Name: Archbold Family Dental
Address: 311 West Holland Street, Archbold, OH, 43502, United States
Telephone: 419-445-8176
Price range: $

Thank you for choosing Archbold Family Dental for your dentistry needs. Please complete the form below, and a member of our team will reach out if we have any questions. If you have any questions, please feel free to contact us.

Become a Patient

Emergency Intake Form

Please fill out our emergency intake form in its entirety to ensure we can provide you with the best possible care.

Note: Any fields with * are required.

Today's Date *

Patient Name *

First

Last

Birthdate *

Phone Number *

Email Address *

Chief Complaint: *

Pain Level 1-10: *

Location of Pain: *

UL - UPPER LEFT
UA
UR - UPPER RIGHT
LL - LOWER LEFT
LA
LR - LOWER RIGHT

Select all that apply: *

Hot
Cold
Throbbing
Dull ache
Sharp pain
Bleeding gums
Lost filling
Trauma
Broken tooth
Other

Please specify. *

Previous Dentist *

Date of Last Visit *

Have you had dental X-rays done? *

When were your X-rays done? *

Insurance *

Insurance ID # *

General notes, if applicable:

Comment

Ready to take the next step?

APPOINTMENT

Contact Us

Dr. Brian Custer is proud to offer comprehensive dentistry to the residents of Archbold, Ohio, and surrounding communities.

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Contact Information

Phone:
419-445-8176
Fax:
419-442-7730
Email:
archboldfamilydental@gmail.com

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Location

311 West Holland Street
Archbold, OH 43502

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Hours

Every other Mon: 8:30AM - 7:30 PM
The following Mon: 8:30 AM - 1 PM
Tue & Thurs: 8:30 AM - 7:30 PM
Sun, Wed, Fri & Sat: Closed
Lunch Hour: 1 PM - 2 PM

Get in touch!

Fill out the form below, and a member of our team will get back to you shortly.

Name *

First

Last

Email *

Phone

How can we help you? *

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