Emergency Appointment - Lowton Dental Centre

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Emergency Appointment

Please note, this form is for registered patients only and forms sent over the weekend will only be picked up on a Monday morning

Name *

Date of Birth *

Address *

Postcode *

Telephone Contact *

Email *

Do You have a new continuous cough? *

Yes
No

Do You have a temperature above 37.8 degrees? *

Yes
No

Are you suffering from a shortness of breath? *

Yes
No

Are you self-isolating? does anyone in your family or support bubble have symptoms? Are you living with a COVID-19 positive person? *

Yes
No

Have you had a COVID-19 positive test? *

Yes
No

Are you in pain? What is the pain level?

Do you have any swelling?

Yes
No

Do you have any bleeding ?

Yes
No

Please describe the location of the pain, swelling or bleeding

Does anything make the pain better or worse? (Eg: hot/cold/biting/brushing)

Are you taking any pain relief?

Yes
No

If yes, what are you taking? Is it effective?

Please provide a list of any medications you are taking. If you are not taking any medication, write 'None' *

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