Turn pediatric dental emergency enquiries into consultation-ready
Parents describe the current issue, when it started, and whether their child can eat, drink, or open their mouth normally, then upload a photo of the injury or swelling so your team can triage before the phone rings.
The exact intake your pediatric dental emergency leads complete
This is the real 6-question guided intake for Pediatric Dental Emergency — the same flow your customers finish before you ever pick up the phone.
What a qualified pediatric dental emergency lead should tell you
Urgent-care qualification for a child with acute dental trauma or pain, capturing symptom type, how long ago it started, and whether the child can eat, drink, or open their mouth so staff can decide who needs same-day chair time.
- Best Describes Current Issue
- Old Child
- Did This Problem Start
- Child Unable Eat, Drink,
- Child Had Fever Since
- Parent Or Legal Guardian
The questions your team needs answered
Every pediatric dental emergency intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| What best describes the current issue? | The weight gap between a knocked-out tooth and a general 'other issue' answer is what separates an urgent same-day case from a routine callback. |
| How old is the child? | Age isn't weighted for urgency but gives staff clinical context on how to approach the child before the consultation. |
| When did this problem start or the injury occur? | A near-10-point gap between 'within the last hour' and 'more than a week ago' means recency alone can push a case into or out of same-day priority. |
| Is the child unable to eat, drink, or open their mouth normally? | Inability to eat, drink, or open the mouth is weighted heavily because it signals functional impairment that usually needs prompt evaluation. |
| Has the child had a fever since the injury or problem started? | A fever since the injury is weighted to flag possible infection, which raises the case above a similar injury without fever. |
| Are you the parent or legal guardian able to authorize care for this child? | Treatment can't proceed without consent, so a low weight on 'no' surfaces the need for a callback before any chair time is booked. |
How Cliont scores pediatric dental emergency leads
Every answer is weighted automatically — no manual review required.
Value signals
- Knocked-out tooth
- Facial or gum swelling
- Ongoing mouth bleeding
- Loose tooth after injury
- Other issue
- Within the last hour
Urgency signals
- Severe tooth pain
- Chipped or broken tooth
See the lead your team receives
Pediatric Dental Emergency 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 pediatric dental emergency workflows
| Cliont capability | Pediatric Dental Emergency application |
|---|---|
| Weighted answer scoring | Scores a knocked-out tooth at the top of the scale and a chipped tooth lower, so the highest-severity current-issue answers surface first. |
| Time-sensitive question logic | Combines the onset-time answer with the current-issue answer so a case reported within the last hour scores well above the same issue reported a few days ago. |
| Consent gating | Flags leads where the guardian authorization answer is no, so staff follow up on consent before chair time gets reserved. |
| Photo capture in the intake | Collects a photo of the injury or tooth and any facial swelling directly in the form, so staff can assess severity before calling back. |
| CRM routing | Sends qualified emergency leads to your CRM tagged with symptom type and onset time so front-desk staff can prioritize same-day slots without re-asking questions. |
Common pediatric dental emergency lead scenarios
Knocked-out tooth within the hour
The intake flags this as top priority since the current-issue weight is highest and onset within the last hour matters for re-implantation, pushing it straight to same-day scheduling.
Facial swelling with a fever
Swelling and fever both carry heavy individual weights, so a child showing both is scored as a probable infection needing prompt evaluation rather than a routine callback.
Chipped tooth from days ago
An older onset combined with a lower-weighted issue type scores well below a fresh injury, letting staff route it to the next available slot instead of interrupting the day.
Loose tooth, child eating fine
When the child can eat, drink, and open their mouth normally, the low weight on that answer offsets the injury itself, so the lead lands as worth a follow-up rather than an urgent case.
No guardian available to authorize care
A 'no' on guardian authorization scores low on that question regardless of how severe the symptom is, so the intake surfaces it for a callback to confirm consent before any chair time is booked.
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 pediatric dentistry intake templates
Pediatric Dental Emergency lead-intake FAQs
How does the intake tell a knocked-out tooth apart from a chipped tooth in urgency?
The current-issue question weights a knocked-out tooth at the top of the scale and a chipped tooth lower, and that weight combines with how recently the injury happened so a fresh avulsion outranks an older chip every time.
What happens if the guardian authorization answer is no?
Guardian authorization carries a low weight when the answer is no, which lowers the lead's score and signals staff to reach out and confirm who can consent before any appointment gets booked.
Why does the intake ask the child's age if it isn't scored?
The age ranges don't carry urgency weight because a young child and a teenager can both have equally severe injuries, but the answer still gives your team clinical context before the consultation.
Can this intake decide if a case needs the ER instead of the practice?
No, the intake only scores and routes the qualification answers your team supplied; it doesn't make a medical determination, so severe trauma should still be handled per your practice's clinical judgment.
What photos does the intake collect for an emergency case?
It asks for a photo of the injury or affected tooth, and a photo of any facial or gum swelling, so staff can see the situation before returning the call.
How is this different from the child cavity treatment intake?
Pediatric dental emergency intake weighs onset time and functional symptoms like eating and mouth-opening heavily to catch same-day cases, while child cavity treatment intake is built around scheduling routine restorative work instead of triage.
Turn pediatric dental emergency visitors into qualified patients
Give every pediatric dental emergency visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.