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Have you had any operations or been admitted to hospital in the last 12 months?

Yes

Are you over 18?

Yes

Do you smoke, drink alcohol or use any recreation drugs?

Yes

Are you experiencing any of the following symptoms?

Uncontrolled fever, Chills, Feeling Weak or Dizziness

Unexplained Rash, Seizures

Vomiting, Abdominal Pain or Diarrhoea

Difficulty Breathing, Increased Heart Rate or Increased Breathing Rate

Extensive swelling reaching the eye or going into the neck

Restricted swallowing, Struggling to speak or Struggling to open your mouth

None of the above

Are you allergic to Penicillin or Beta lactams?

Yes

Do you have any other allergies

Yes

Do you suffer from Kidney or Liver Disease?

Yes

Do you take any other medication (from your GP, over-the-counter or herbal medication)?

Yes

Have you been clinically diagnosed with any medical conditions?

Yes

If you are female, are you pregnant, planning to get pregnant or breastfeeding?

Yes

Have you taken this medicine before with a prescription in less than 6 months ?

Yes

Which part of the gum/mouth is the suspected infection located? (For example, left upper, right lower , rear or front)

Are you experiencing any of the following DENTAL symptoms?

Please select what applies (NOTE: let us know what dental symptoms you are experiencing for us to complete a supply of antibiotic prescriptions. Failure to do so may delay assessment of your consultation)

A) An intense throbbing pain in the affected tooth or gum area that comes on suddenly and is worsening

B) Pain that is spreading to the ear, jaw and neck on the same side as the affected tooth or gum C) pain that is worse when lying down

D) Redness, swelling or both on the face

E) Tender, discoloured or loose tooth

F) Red swollen gums or bad breath and unpleasant taste in the mouth

G) Any other dental related issues?

H) None of the above

Can you confirm whether you have seen or attempted to make contact with a dentist?

Yes

Do you agree not to drink alcohol when taking this type of medication?

Yes

I confirm I have capacity to make health decisions, will read the patient leaflet, report side effects, consent to record access, confirm my information is accurate, will see a dentist soon, and accept the terms and privacy policy.

Yes

To support your care, we kindly ask for your GP details. If treatment is supplied, we may notify them. Providing accurate information helps avoid any delays.

Enter GP details Manually or search via GP postcode/name.

Yes

Assessment

Dental Infections & Abscesses Consultation

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