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
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
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
Number of teeth crumbling
Number of teeth with pain
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?
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Well done you did it! d