Emergency Appointment - Lowton Dental Centre

Skip to content

Home
About
- What We Do
- Meet The Team
Emergency Appointment
Treatments
Patient Information
Contact Us
Gallery

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' *

Treatments

What We Do

Recent Posts

Invisalign Smile Day
Patient Finance

Recent Comments

Archives

November 2021
October 2021

Categories

Uncategorized

Meta

Log in
Entries feed
Comments feed
WordPress.org