Virtual Consultation Booking Form

How would you like to consult?

The consultation fee is deducted in full from your in-clinic visit fees.

What would you like advice on? Select all that apply

About you

Full name Email

Mobile / WhatsApp

Country of residence

We will contact you by

Medical questionnaire

So your specialist can advise safely. Confidential to your clinical team.

Diabetes

Heart condition or high blood pressure

Blood-thinning medication

Smoker

Pregnant or breastfeeding

Allergies (e.g. penicillin, latex)

Previous gum disease or gum treatment

Surgery or hospital stay in the last 12 months

Please list your allergies When, and what treatment did you have? What surgery, and when? Current medication, if any

Your records and timing

JPG, PNG, PDF or DICOM (.zip) · up to 25 MB each · drag and drop or browse

Photos to take: Front smileTeeth togetherUpper teethLower teethGum line, each side See the photo guide

What would you like to achieve?

Choose your video appointment Times in East Africa Time (UTC+3)

Will you travel to Nairobi for treatment?

Our patient liaison can arrange the details for you.

Arriving Departing

Review and confirm

Consultation

Advice on

Travel support

Due today

Payment method

No payment is needed for a written second opinion. If you would rather discuss it by video, go back and choose a Live video consultation (KES 3,000).

I consent to Summit Dental Care processing my health information and images to provide this consultation, in line with the privacy policy. Required I understand a virtual consultation gives clinical guidance and does not replace an in-person examination. Required Keep me informed about clinic news (optional)

Reference SDC-VC-[number] · A confirmation is on its way to you now.

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2Specialist reviewYour records are assessed by the specialist best suited to your treatment.
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SUMMIT DENTAL CARE

Arrange your virtual consultation