Dental Infection Form

Dental Infection Form (#16)

Welcome to AHMU Clinic, Begin Your dental infection medication consultation

We’ll ask a few questions to assess your eligibility, which will take around 2 minutes. When you're done, press complete and one of our clinicians will review your answers.

Please Enter Your Full Name

Please Enter Your Date of Birth

Please Upload your picture ID for Verification

Select File

Please Enter your sex at Birth

Male

Female

Please Enter the Full Address including Post code of your GP

Address Line 1

City

County

Post Code

Country

Patient Mobile Number

Alternative Contact Number:

Please Enter your NHS Number

Please Enter Name of your GP

Are you aged 18 years or over?

Yes

Are you breastfeeding?

Yes

Are you Pregnant?

Yes

Are you currently experiencing any of the following?

Difficulty breathing

Difficulty swallowing

Swelling spreading to the eye or neck

Difficulty speaking

Difficulty opening your mouth (trismus)

Fever with chills or feeling faint/weak

Rapid breathing or increased heart rate

Severe facial swelling worsening rapidly

None of the above

Where is the suspected infection located? (e.g. upper right molar, lower left gum)

Please specify!

How long have you had these symptoms?

Have your symptoms worsened in the last 24–48 hours?

Yes

Have you taken antibiotics in the last 4 weeks?

Yes

Please state which antibiotics did you take in the last 4 weeks and when?

Have you taken antibiotics for a dental infection in the last 6 months?

Yes

Please state which antibiotics for Dental Infection in last 6 months?

Have you contacted or seen a dentist about this issue?

Have you ever been diagnosed with any of the following?

Have you been admitted to hospital or had major surgery in the last 12 months?

Yes

Please provide details

If you have any other medical conditions not listed above, please provide details.

Are you currently taking any prescription, over-the-counter, or herbal medicines?

Yes

Please provide details

Do you have any medicine allergies?

Yes

Please list the allergies...

Amoxicillin is usually the first-choice antibiotic for dental infections (where clinically appropriate). Have you taken Amoxicillin before, and if so, did it successfully treat your dental infection?

No, I have not taken Amoxicillin before

Yes, and it worked successfully

Yes, but it did NOT work successfully

Please briefly explain why Amoxicillin did not work

Are you allergic to penicillin or beta-lactam antibiotics (e.g. amoxicillin, flucloxacillin, co-amoxiclav)?

Yes

Unsure

Describe reaction

Do you smoke?

Yes

Do you drink alcohol?

Yes

If treatment is supplied, please confirm:

I will take the medication exactly as prescribed.
I understand I must complete the full course unless advised otherwise.
I understand I must avoid alcohol if advised with the prescribed antibiotic.
I will seek urgent medical help if symptoms worsen or red flag symptoms develop.

I confirm that I understand and agree to the above

I confirm.

Please confirm:

The information I have provided is accurate and complete.
I consent to this remote clinical assessment.
I understand antibiotics may not be prescribed if not clinically appropriate.
I understand this does not replace a face-to-face dental examination.
I will arrange a dental appointment as soon as possible.
I agree to read the patient information leaflet before taking any medication supplied.
I understand side effects can be reported via the Yellow Card Scheme managed by the MHRA.

I confirm that I understand and agree to the above

I confirm.

We may contact your GP if clinically necessary in line with professional guidance from the General Pharmaceutical Council.

Yes

Please Select your choice of treatment

Metronidazole Tablets

Amoxicillin 500mg

Duraphat 5000

Duraphat 2800

Welcome to AHMU Clinic, Begin Your dental infection medication consultation

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