New Patient History Form Full Name*Email* Phone*Where are you located?*How did you hear about Dr. O'Rielly?*Are you currently in pain?*Describe the pain: its location, its strength from 1-10 and how long you have had it.What dental issues do you have that you would like Dr. O’Rielly’s help to resolve?*When was your last set of Xrays taken?*Please e-mail them to [email protected] How many root canals do you have or need?*Have you had any problems, or pain with them?Please list the dentists and/or specialists you have seen over the last year, and the treatment that has been recommended to you.Has the treatment been done? Has there been any difficulties or complications with past treatment? This will help us to understand your unique needs and situation.Are you currently in treatment for any health challenges?