Smile Dental Chat | Online Dental Consultation

Section 1: Pain Assessment

How would you describe your pain?

Sharp/Stabbing

Dull/Aching

Throbbing

Only when biting

Sensitive to Hot/Cold

Pain Severity (1-10)

1 (Mild) 10 (Unbearable)

How long has this bothered you?

Section 2: Visible Symptoms

Check all that apply:

Swelling in the gums or face

Bleeding while brushing/flossing

A loose tooth

Visible cavity or "hole"

Redness or pus near a tooth

Bad breath or foul taste

Section 3: Habits & History

Daily Habits

Smoking/Tobacco

Teeth Grinding

High Sugar Intake

Are you currently taking any medications?

Health Conditions

Section 4: Previous Dental History

Have you ever had or do you currently have any of the following?

Root Canal Treatment

Dental Implants

Dental Bridges

Dentures (Partial or Full)

Gum Diseases (Periodontitis)

TMJ Procedures / Jaw Pain Treatment

Other Previous Procedures

Section 5: Diagnostic Uploads

Upload X-ray / OPG / Reports

Max size 10MB per file.

Photo of Affected Area (Optional)

Tip: Use your smartphone flash for a clearer image.

Section 6: Payment Information

Select Payment Mode

Please ensure payment is completed before submitting.

Transaction ID / Reference Number