Name *

First Name

Last Name

Date Of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Do you have any of the following? *

Facial swelling

Throbbing toothache

Pain when biting or chewing

Pus or bad taste in the mouth

Swollen gums

Fever or chills

Difficulty opening mouth

None of the above

🚩Have you experienced any of these symptoms? *

Swelling affecting your eye or eyelid

Difficulty breathing or swallowing

Rapidly increasing swelling

Severe facial pain with confusion or high fever

None of the above

Do you have any allergies to antibiotics or medications? *

Yes

No

Are you pregnant or breastfeeding? *

Yes

No

Have you seen a dentist about this issue? *

Yes

No

I have an upcoming appointment

Do you understand that antibiotics alone won’t resolve the abscess? *

Yes

No

Have you had a dental abscess treated before? *

Yes

No

Consent & Declaration *

I understand that this service is not a substitute for dental care.

I agree to see a dentist as soon as possible.

I understand that antibiotics may not be appropriate if no signs of spreading infection are present (per NICE guidelines).

I confirm all answers above are true and accurate.

I consent to treatment if deemed suitable.