COVID-19 Forms Please note, it is important that the forms are completed on the day of your appointment in the morning. Personal detailsFull Name* Please SelectMrMrsMissMsDrProf.Rev. Prefix First Last Date of Birth* DD MM YYYY Sex*MaleFemaleAddress* Street Address Address Line 2 City ZIP / Postal Code Mobile number*Home numberEmail* 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 infectedHave you been tested for COVID 19?*YesNoPlease provide more details*Have you had COVID 19?*YesNoDo you have fever or have you felt hot or feverish recently (14-21 days)?*YesNoDo you having shortness of breath or other difficulties breathing?*YesNoDo you have a cough?*YesNoHave you been abroad in the last 6 months?*YesNoAny other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*YesNoHave you experienced recent loss of taste or smell?*YesNoAre you in contact with any confirmed COVID-19 positive patients? (Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment)*YesNoIs your/their age over 60?*YesNoDo you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*YesNoHave you travelled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)*YesNoWhere and when ?*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 Date Format: DD slash MM slash YYYY CommentsThis field is for validation purposes and should be left unchanged.