24-7 Emergency Dental Clinic

Medical Record Form for Emergency Virtual Consultations

Full Name *

Email *

Date of birth

Phone *

Medical History:

Do you have any pre-existing medical conditions? (Diabetes, hypertension, etc.)

Yes

No

Please list any pre-existing medical conditions if you marked yes.

Are you currently taking any medications?

Yes

No

List any medications if you answered yes.

Do you have any allergies to medications?

Yes

No

List any medication allergies if you answered yes.

Dental Information:

What is the nature of your dental emergency?

Toothache

Swelling or inflammation

Bleeding

Broken or fractured tooth

Other dental emergency? Specify here.

How long have you had this problem?

Less than 24 hours

1-2 days

More than 2 days

Have you experienced this problem before?

Yes

No

If you've experienced this problem before, specify here.

Consent for Virtual Consultation:

I understand that the virtual consultation will be conducted by a licensed dental professional and that medications may be prescribed based on the information provided and the assessment made during the virtual consultation.

Virtual consultation day?

Patient's Signature:

Clear

Captcha

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