Name and Contact Information

Name

Address  

 City  

State  

Zip  

Alternate mailing address such as a PO box  

Email  

Other back up email  

Phone  

SSN (for medical records) If you do not want to provide it, tell us you will provide it later

Social Media profile / handle name (we recommend this as a back up way to notify you if there is a payment to you)   

Best Contact Time / contact instructions

Secondary/Emergency Contact Name

Emergency Email

Emergency Phone

Suboxone Film Use

When did you start taking Suboxone FILM?

Dosage that you have been taking of the Suboxone FILM 2mg4mg8mg16mg

 Have you taken any other type of Suboxone such as the pill tablet?

 If you took the Suboxone pill tablet, when did you start taking it?   

 If you took the Suboxone pill tablet, when did you stop taking it?  

If you have not stopped taking the pill tablet please say “I’m still taking the pill tablet” here

How many times each day do / did you take the SUBOXONE TABLET?

How many times each day are you or were you taking the SUBOXONE FILM OnceTwiceThree times

When did you have the first signs of dental damage ?

What type of dental damage have you experienced?

Did you start taking Suboxone for pain management or opioid addiction?

Number of teeth lost 1-45-89-1213-20All 

Number of teeth crumbling 1-45-89-1213-20More than 20

Number of teeth with pain 1-45-89-1213-20More than 20

Did you ever use methamphetamine?

Prescribing Doctor (include city and state):    
Name:  

Pharmacy product was filled at, including city and state:  

Pre-Use Suboxone Dental Care

BEFORE taking Suboxone, did you have cavities, periodontal disease or lost teeth ?

If other dental damage, please describe

                Dental Care Pre-Use Provider Information

Dental Office Name or Dentist Name (If you don't know, then state "I don't know")

Address (If you don't know then state "I don't know")

Phone

Start Treatment Date

End Treatment Date

Dental Care After Starting Suboxone (Post-Use)

What is the name of the dental office or dentist who gave you dental treatment  after you started Suboxone?Provider Dental Office Name or Dentist Name

Address

Phone

Start Treatment Date

End Treatment Date

What types of treatment have you had during the time after you started Suboxone?

Leave this empty:

Your legal name

Your email address

Signature Certificate

Document name: Suboxone Intake

Unique Document ID: 3d197efb26601c1448fbe2638b9fae2ff14305e9

Build. Track. Sign Contracts.

Timestamp	Audit
March 4, 2026 3:03 pm PDT	Suboxone Intake Uploaded by Law Offices of Jennifer Duffy - admin@nationwideinjurylawfirm.com IP 2603:8000:7301:e00c:b1e4:8d2d:f42:1a5

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