Patient of the PracticeNew PatientFirst ContactRe-Contact How Much Pain Do You Feel? MildModerateSevereUncontrollable What kind of emergency do you have? --Please Select--SwellingBleedingBroken ToothOther Medical History Please Select Any Medical Conditions We Need To Be Aware Of: High or low blood pressureHeart MurmurStrokeParalysis Artificial Heart ValveAnginaAsthma/ BronchitisHay fever or eczemaBrain surgeryNeurological (nerve) diseasesArthritisHIVHepatitis / JaundiceLiver or Kidney diseaseFainting attacks/giddinessBlackouts or epilepsy Do you Have Any Allergies ParacetamolIbuprofenPenicillinMetronidazoleAspirinOther Are You Currently Take Any Medications? AnticoagulantsBisphosphonates for bonesOsteoporosisOther Are You Pregnant? YesNo Are You A Smoker? YesNo Are You A Drinker? YesNo Covid-19 Risk Assessment Any new continuous cough? YesNo Temperature above 37.8°C? YesNo Shortness of breath? YesNo Self-isolating/has symptoms/anyone in family has symptoms/living with a Covid-19 positive person indoors/over 70 years old/has one or multiple underlying medical history risk? YesNo Covid-19 positive diagnosis? YesNo Upload Up To 2 Pictures Tell Us More I consent to my personal data being collected and stored as per the Privacy Policy. I consent to my personal data being collected and stored for the purpose of marketing communications.
