Know which broken tooth leads are worth consultation time
Patients tell you whether the tooth is loose, chipped, or fully broken, how much pain they're in, and how soon they need care, with a tooth photo attached before they ever call your office.
The exact intake your broken or chipped tooth leads complete
This is the real 6-question guided intake for Broken or Chipped Tooth — the same flow your customers finish before you ever pick up the phone.
What a qualified broken or chipped tooth lead should tell you
Assessment of a cracked, chipped, or fractured tooth to determine pain level, extent of structural damage, and how quickly the patient needs to be seen for treatment.
- Experiencing Pain Or Sensitivity
- Would Describe Extent Damage
- There Any Bleeding From
- Did Tooth Become Broken
- Soon Be Seen This
- This Yourself Or Child
The questions your team needs answered
Every broken or chipped tooth intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| Are you experiencing pain or sensitivity from the broken or chipped tooth? | Reported pain or sensitivity is a direct signal of how much the tooth is affecting the patient day-to-day and how urgently they'll want a response. |
| How would you describe the extent of the damage to the tooth? | The damage-extent answer is what separates a cosmetic chip from a tooth that's loose or missing a large piece, which drives most of the lead's priority score. |
| Is there any bleeding from the gum or mouth around the tooth? | Bleeding around the tooth or gum points to a more acute injury that likely needs faster attention than a clean chip with no soft-tissue involvement. |
| How did the tooth become broken or chipped? | Segments the lead so you can route, price, and prioritize it correctly. |
| How soon are you looking to be seen for this issue? | How soon the patient wants to be seen tells your front desk whether to offer today's opening or a slot later in the week. |
| Is this for yourself or for a child or dependent in your care? | Knowing whether the case is for the patient or a dependent lets staff prepare the right kind of appointment before the patient walks in. |
How Cliont scores broken or chipped tooth leads
Every answer is weighted automatically — no manual review required.
Value signals
- Experiencing Pain Or Sensitivity: yes
- Small chip in the enamel
- Visible crack but tooth intact
- Tooth feels loose or moved out of place
- Not sure
- There Any Bleeding From: yes
Urgency signals
- Experiencing Pain Or Sensitivity
- Large piece broken off
- Immediately, today
See the lead your team receives
Broken or Chipped Tooth Lead
From first click to qualified lead
Follow patients and caregivers through one smooth, guided flow.
They land & meet you
Your video greeting plays instantly — a real face instead of a blank form.
They explain the visit
Smart questions adapt to their visit and capture the full scope.
They share details
Symptoms, history, and documents come attached before the visit.
You get a ready lead
Scored and qualified — waiting for you to win it.
Built for broken or chipped tooth workflows
| Cliont capability | Broken Or Chipped Tooth application |
|---|---|
| Weighted scoring | Ranks a tooth reported as loose or largely broken off above a small enamel chip, so your team calls back the more urgent case first. |
| Photo capture | Collects a close-up of the broken tooth before the consultation so staff can gauge severity without waiting for the patient to describe it over the phone. |
| Dependent flagging | Surfaces whether the intake is for the patient or a child in their care, so front desk staff can prepare a pediatric-appropriate slot. |
| Urgency-based routing | Separates 'immediately, today' requests from 'just exploring options' responses so same-day chair time only goes to leads who actually need it. |
Common broken or chipped tooth lead scenarios
Tooth loose after a fall
Patient reports the tooth feels loose or moved out of place with pain and gum bleeding, and wants to be seen immediately, which pushes this to the top of the queue.
Small enamel chip, no pain
Patient chipped a tooth on food, reports no pain or bleeding, and is just exploring options, which still qualifies but doesn't need same-day chair time.
Child's tooth chipped at school
A parent fills out the intake for a dependent after a visible crack from an accident, prompting scheduling that accounts for the patient being a minor.
Unsure how bad the damage is
Patient can't tell how the tooth broke or how severe the damage is, so the intake relies on their photo and pain answer rather than the cause field to route the lead.
Connect Cliont to your workflow
Send leads
HubSpot, HighLevel, Salesforce, JobNimbus
Book visits
Google Calendar, Outlook Calendar, Calendly
Notify your team
Email, SMS, Slack
Automate follow-up
Zapier, Webhooks, API
Simple, transparent pricing
Choose the plan that works for your business.
Professional
Unlimited intake forms and leads for your growing business.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Advanced analytics dashboard
Pay Per Lead
Only pay when you receive a qualified lead.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Charged only for submitted leads
More emergency dentistry intake templates
Broken or Chipped Tooth lead-intake FAQs
How does the intake decide a broken tooth lead is high priority?
It weighs the damage-extent answer alongside reported pain and gum bleeding, so a tooth that feels loose or has a large piece broken off scores higher than a small enamel chip.
Can the form tell a cosmetic chip apart from a tooth that needs urgent stabilization?
Yes. The damage-extent question separates a small chip in the enamel from a tooth that's loose or moved out of place, so your team can see the difference before responding.
What happens when the intake is for a child instead of the patient themselves?
The form asks whether the case is for the patient or a dependent in their care, so pediatric cases are identifiable in your CRM without a phone call.
What if a patient doesn't know how the tooth broke?
The cause question includes a 'Not sure' option, so the lead still comes through complete and your team can ask follow-up questions at the consultation instead of the patient guessing.
Does the intake separate same-day emergencies from patients who can wait a few days?
Yes, the how-soon question captures whether someone wants to be seen immediately, within 24-48 hours, or is just exploring options, which lets you fill urgent openings first.
What photo should I require for a broken or chipped tooth intake?
A close-up of the tooth and surrounding gum line gives your team a visual read on damage extent and any bleeding before the patient arrives.
Turn broken or chipped tooth visitors into qualified patients
Give every broken or chipped tooth visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.