COVID-19 Form - Dental Touch Bristol

Personal details

Full Name*

Date of Birth*

Sex*

Male
Female

Address*

Street Address Address Line 2 City ZIP / Postal Code

Phone*

Email*

Enter Email Confirm Email

COVID-19 Patient Screen Form

I am aware that the current COVID-19 pandemic brings a number of known risks and a number of unknown risks. I have chosen to seek dental treatment during the pandemic in the knowledge that much is still unknown about the virus.

Consent

I understand the coronavirus that causes COVID-19 has a long incubation period during which time carriers of the virus may not show symptoms yet still be highly infectious. I also understand that some people may have the virus but may not ever have any symptoms. I therefore understand it is impossible to determine who has the virus and I understand that I must assume that anyone anywhere could be infected

This field is hidden when viewing the form

Do you have a confirmed diagnosis of COVID-19?

Yes
No

This field is hidden when viewing the form

Please provide more details*

Do you have any of the following symptoms:*

High temperature or fever?
New, continuous cough?
A loss or alteration to taste or smell?

Yes
No

Have you or any member of your household/family had a confirmed diagnosis of COVID-19 in the last 10 days?*

Yes
No

Are you or any member of your household/family waiting for a COVID-19/SARS-CoV-2 PCR test result?*

Yes
No

Have you or any member of your household/family been advised to isolate by any NHS organisation in the last 10 days?*

Yes
No

Have you travelled internationally in the last 10 days to a country that is on the government red list?*

Yes
No

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

Consent COVID-19*

please tick to confirm the information is correct

Signature*

Signature COVID-19

Date - Signature COVID-19

Name

This field is for validation purposes and should be left unchanged.

COVID-19 Forms

Personal details

COVID-19 Patient Screen Form

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.