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COVID-19 Triaging Questionnaire for Urgent Dental Treatment

COVID-19 Triaging Questionnaire for Urgent Dental Treatment

  • Date Format: DD slash MM slash YYYY
  • COVID-19 Risk Assessment

  • Medical Health Assessment

    Please tick YES or NO for each medical condition AND write down medication taken if applicable.
  • Please list any medications not already listed including recreational usage
  • Urgent Dental Problem

    Please describe the nature of your urgent dental problem
  • Swelling

    Only fill in this section if there is swelling.
  • Dental Trauma

    Only complete this section if you have suffered dental trauma. If you are experiencing bleeding that is severe and ongoing please ring the hospital immediately for advice.
  • Note: Photos can be uploaded at the end of this form
  • Dental Pain

    Please indicate (tick next to) your level of pain: 0-10 (0 = nothing and 10 = worst pain)
  • Photo(s)

    If appropriate, please feel free to take a maximum of 2 photos and upload them here
  • Accepted file types: jpg, gif, png.
  • Consent

  • Date Format: DD slash MM slash YYYY
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