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Details
Date & time
Payment
Video call
Personal information
Full name
Email
Phone number
Age
Sex
Select
Female
Male
Other
Marital status
Select
Single
Married
Divorced
Widowed
Occupation
Address
Chief complaint
What's the issue?
Select an option
Tooth pain
Broken tooth
Cavity
Gum issue / bleeding
Routine checkup
Other
Describe it in your own words
(e.g. "I have pain in the right lower back tooth")
History of presenting illness
Onset
Select
Sudden
Gradual
Duration
Location
Select
Localised
Referred
Radiating
Progression
Select
Continuous
Intermittent
Associated complaints
(select all that apply)
Pain
Swelling
Ulceration
Burning sensation
Bleeding gums
Medical history
Blood pressure
Diabetes
Select
No
Yes - controlled
Yes - uncontrolled
Cardiac abnormalities / blood thinners
(mention if on aspirin, clopilet, clopidogrel, etc.)
Drug allergy
Pregnant?
Not applicable
No
Yes - 1st trimester
Yes - 2nd trimester
Yes - 3rd trimester
Past dental history
Any dental treatment you've had before
Any complications you faced with past treatment
Habits
Smoking
(frequency & duration)
Alcohol
Select
No
Occasionally
Regularly
Paan / tobacco chewing
Select
No
Occasionally
Regularly
Investigations
If you have a dental X-ray, what type?
(OPG or IOPA — optional)
I don't have one
OPG
IOPA
Other
Upload a photo of the affected tooth and/or your x-ray
(optional but recommended — JPG, PNG or PDF, up to 8MB each)
Drag files here, or click to browse
Files upload immediately and are attached to your booking
