Waiting List Form | Compassion Dental

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Patient Waiting List Form

If you would like to be added to our waiting list, please fill out the form below and submit it for approval. Someone from our office will get back to you when we via email or phone to discuss your submission.

You may also call us at 775-358-8913

or email Info@CompassionDental.org

First Name

Cell Phone

Last Name

Home Phone

May we contact you via text?

Yes

Address: including city, state, and zip

Birthday

How did you hear about us?

How many people live in your household?

Estimated Monthly Household Income

Do you have dental insurance?

Yes

If yes, what type?

What are your dental concerns? (i.e broken teeth, cavities, infections, etc.)

Pain level: 0-10

If you're in pain, what makes it better or worse?

How often do you brush your teeth, floss, and use an oral rinse?

When did you last have your teeth profesionally cleaned?

Have you had any major surgeries?

Have you ever been told to premedicate? (Take an antibiotic BEFORE you recieve dental care?)

Yes

Are you currently taking any blood thinners?

Yes

If yes, please list which ones:

Do you have any allergies to medication, latex, or anything else?

Do you have any prayer requests?

Would you have access to reliable transportation to and from your dental appointments?

Yes

Are you available for last minute/same-day appointments in the event someone cancells?

Yes

Any additional comments, questions, or things you would like us to know?

Thanks for submitting! We'll get back to you as soon as we can. Please check out our "Patient Resources" page, where you can find additional resources that may be able to assist you.

Email: info@compassiondental.org
Tel: 775-358-8913

840 I St Suite 4

Sparks, NV 89431

See location on map

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