COVID-19 Forms Please note, it is important that the forms are completed the day before your appointment. Personal detailsFull Name* Please SelectMrMrsMissMsDrProf.Rev. Prefix First Last Date of Birth* Day Month Year Sex* Male Female Address* Street Address Address Line 2 City ZIP / Postal Code Phone*Email* Enter Email Confirm Email COVID-19 Patient Screen FormI 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 infectedHiddenDo you have a confirmed diagnosis of COVID-19? Yes No HiddenPlease 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 correctSignature*Signature COVID-19Date - Signature COVID-19 DD slash MM slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
