APPOINTMENT REQUEST

Reason for Consultation

• New Patient?YN

• Existing Patient Check Up?YN

• Hygiene Visit?YN

• Outstanding Dental Treatment?YN

• Referral For Root Canal Treatment?YN

• Do you require an Emergency Appointment?YN

FOR EMERGENCY APPOINTMENTS ONLY – please complete the following:

Do you have a loose or detached crown?YN

Do you have a broken tooth?YN

Do you have pain?YN

Do you have tenderness?YN

Do you have swelling?YN

Do you have extreme sensitivity to hot / coldYN

How long have you had the problem?

Is this problem a top tooth problem?YN

Is this a bottom tooth problem?YN

Is this problem on YOUR left?YN

Is this problem on YOUR right?YN

Is this problem at the front of your mouth?YN

Is this problem at the back of your mouth?YN

Have you taken antibiotics for this problem?YN

Have you taken painkillers for this problem?YN

Please provide any additional details regarding your problem

Your expectations – what type of treatment would you prefer for this tooth?

Medical History Questionnaire

• Do you take blood thinners?YN

• Do you have any cardiac problems?YN

• Do you have a serious illness?YN

• Do you take any medications we should know about?YN

• Are you allergic to Penicillin?YN

If you have answered ‘YES” to any of the above questions please provide further details

Further Details

• Please provide us with any further details you feel may help us to arrange the most suitable appointment for you below.

• You can attach any relevant photos, previous x-rays or documents below.
  (Each attachment should be in JPG,PNG or PDF format and no larger than 7MB).

• Relevant attachments e.g. photo '1':
  

• Relevant attachments e.g. photo '2':
  

• Relevant attachments e.g. photo '3':
  

• All attached Information is Confidential.

  By sending this request you agree that we may process your data to help you with your enquiry.