Dental Infection - Consultation

Enter your full legal name.

Date of Birth (dd/mm/yyyy)

Are you aged 18 years or over?

Yes

Are you pregnant, planning pregnancy, or breastfeeding?

Yes

Are you currently experiencing any of the following?

Where is the suspected infection located? (e.g. upper right molar, lower left gum)

Which symptoms are you experiencing? (Select all that apply)

How long have you had these symptoms?

Have your symptoms worsened in the last 24–48 hours?

Yes

Have you taken antibiotics for this problem in the last 4 weeks?

Yes

Have you taken antibiotics for a dental infection in the last 6 months?

Yes

Have you contacted or seen a dentist about this issue?

Have you ever been diagnosed with any of the following?

Have you been admitted to hospital or had major surgery in the last 12 months?

Yes

If you have any other medical conditions not listed above, please provide details.

Are you currently taking any prescription, over-the-counter, or herbal medicines?

Yes

Do you have any allergies to medicines?

Yes

Are you allergic to penicillin or beta-lactam antibiotics (e.g. amoxicillin, flucloxacillin, co-amoxiclav)?

Yes

Do you smoke?

Yes

Do you drink alcohol?

Yes

If treatment is supplied, please confirm:

I will take the medication exactly as prescribed.
I understand I must complete the full course unless advised otherwise.
I understand I must avoid alcohol if advised with the prescribed antibiotic.
I will seek urgent medical help if symptoms worsen or red flag symptoms develop.

I confirm that I understand and agree to the above

Please confirm:

The information I have provided is accurate and complete.
I consent to this remote clinical assessment.
I understand antibiotics may not be prescribed if not clinically appropriate.
I understand this does not replace a face-to-face dental examination.
I will arrange a dental appointment as soon as possible.
I agree to read the patient information leaflet before taking any medication supplied.
I understand side effects can be reported via the Yellow Card Scheme managed by the MHRA.

I confirm that I understand and agree to the above

To support safe prescribing please provide your GP details.

Yes

Would you like us to inform your GP if treatment is supplied?

Yes

We may contact your GP if clinically necessary in line with professional guidance from the General Pharmaceutical Council.

Yes