Patient Online Consultation Form

Please complete the form below and then click the submit online consultancy button - thank you.

1. Patient Details

Title:
Forename:
Surname:
Gender:
Address:
Postcode:
Date of Birth:
Home Phone:
Mobile Phone:
Occupation:
Email Address:
Approx. date of last visit:

2. Previous Dental History

Name of Dentist you normally see:
Details of any incomplete treatment:
Have you been in contact with the practice within the last two months?

If yes, please explain when, and who you spoke to:

3. COVID-19 Status

Have you been diagnosed with Coronavirus?
Have you been in contact with someone with confirmed Coronavirus?
Are you or your household self-isolating because of virus symptoms or concerns?
Do you have, or have you had, a temperature (> 37.8 °C) in the last 21 days?
Do you have, or have had, a persistent dry cough in the last 21 days?
Are you in a vulnerable group or at increased risk of Coronavirus? e.g. 70 or older or under 70 with underlying health condition
Are you in a shielded group considered at increased risk of Coronavirus? e.g. underlying health condition, living with someone who needs shielding

4. Recent Dental Care

Have you needed to contact Urgent Care within the last two months?
Who did you receive care from?




Reason for urgent care:
Location of urgent care:
Date of previous care:
Advice given:
Any painkillers advised? If so what?
Medication prescribed:

Radiographs/ photographs taken:

Please attach if available

5. Medical History

Do you have any current medical conditions?
Are you currently taking any medication?
Do you have any allergies? ie. Pencillin or Latex

6. Current Dental Problem

Please describe your current dental problem:
How long has this been causing a problem?
If you have pain please fill in the section below:
Where is the pain coming from?
What causes the pain? e.g. hot, cold, biting
Describe the pain e.g. sharp, aching
When the pain occurs how long does it last? e.g. seconds, minutes, hours
Does anything make the pain better? e.g. painkillers, cold
How severe is the pain, on a scale of 1-10: 1 (no pain) - 10 (worst pain ever)
Has it kept you awake? Does it get worse at night?
Have you taken any painkillers? If so what & dosage
If you have swelling please fill in the section below:
Where is the swelling? Is it inside the mouth or outside the mouth?
How big is the swelling?
How long has the swelling been there?
Please select if you have any of these other issues:




If you are bleeding please fill in the section below:
Where is the blood coming from?
How long does the bleeding last?
How much blood has there been?
Have you recently had a tooth taken out?
If you have had any trauma please fill in the section below:
What happened?
When did this happen?
Any loss of consciousness?
Have you visited A&E?
If you have any other issues please fill in the section below:
Ulcers
Location, Size, Duration?
Orthodontic Appliances
Is it causing soft tissue trauma?
Additional Concerns
Please list any additional concerns not listed in the above sections:
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Site last updated 23.09.2020