AUDO Emergency Intake (PDF Preview + Email) Dental Emergency Patient Questionnaire All fields required → Generate PDF preview → Send PDF to clinic (attached by email). 1) Patient & Contact Full Name Date of Birth Nationality Email Mobile Phone WhatsApp (if different) Current Address in Japan (Hotel / Residence) Preferred Language English Japanese Other If Other, specify (or write N/A) 2) Emergency Contact Name Relationship Phone 3) Reason for Emergency Visit Main concern (select at least one) Tooth pain Swelling Broken / chipped tooth Lost filling / crown Trauma / accident Gum pain / bleeding Infection / abscess Broken or lost retainer Other (write N/A if none) When did it start? Select Today1–2 days3–7 daysMore than 1 week Pain level (0–10) Fever or swelling? SelectNoYes 4) Medical History Medical conditions (select at least one) Heart disease High blood pressure Diabetes Asthma Bleeding disorder Seizures / epilepsy Pregnancy Immunocompromised None Other medical condition (write N/A if none) Current medications (write None if none) Medication allergies (write None if none) 5) Dental History Last dental visit Select < 6 months6–12 months> 1 yearUnknown Existing dental work/appliances (select at least one) Crowns / bridges Implants Root canal treated teeth Braces / retainers Occlusal splint / Night guard Dentures None Previous complications with dental treatment or anesthesia? SelectNoYes Details (write N/A if no) 6) Travel & Time Sensitivity Current status SelectLiving in JapanTraveling Planned departure date Need urgent treatment completed before departure? SelectNoYes 7) How Did You Find AUDO? Select at least one Google search Google Reviews Clinic website Hotel Embassy / Consulate Insurance / Assistance company Friend / Family Dentist / Clinic referral Walk-in Other (write N/A if none) 8) Insurance Do you have insurance? SelectNoYes Insurance company (write N/A if none) Insurance type (select at least one) Japanese National Health Insurance International / Overseas Insurance Travel Insurance Embassy / Corporate Insurance No insurance Need documents for reimbursement? SelectNoYes 9) Consent I confirm the information is accurate. Emergency treatment may be limited to pain relief or stabilization. Generate PDF Preview Send PDF to Clinic Clear Final PDF Preview If correct, tap “Send PDF to Clinic”.
