Tel: 0117 9238 400 Fax: 0117 9467 007 Email: info@rootfillings.com

Feedback Form

If you wish to print out the feedback form and bring it with you to the practice, please click here:-

    • Dull ache:
    • Throbbing pain:
    • Tender over the gum:
    • Tender to biting:
    • Sharp, stabbing pain:
    • Tender only where the injection was given:
    • Immediately after the anesthesia wore off:
    • Later that same day:
    • Next day:
    • 2 days later:
    • After 2 days:
    • Same
    • Increasing daily
    • Decreasing daily
    • I am not sure
    • Not present now
    • Very minor now
    • Episodic
    • None
    • ASA/Aspirin
    • Tylenol
    • Codeine or other narcotic (Vicodin)
    • Non-steroid anti-inflammatory
    • (Drug name: )
    • How many pills did you take?
    • Over how many days?
    • Yes:
    • No:
    • No pain:
    • Very minor pain:
    • Moderate pain:
    • Severe pain:
    • Not painful at all:
    • Very minor pain - less than I had expected:
    • Moderate pain - about what I had expected:
    • Extremely painful:
    • No injection given:
    • Superlative care:
    • Competent and caring:
    • Competent and uncaring:
    • Incompetent and caring:
    • Incompetent and uncaring:
    • Very satisfied:
    • Satisfied:
    • Dissatisfied:
    • Very satisfied:
    • Satisfied:
    • Dissatisfied:
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