I have to pay for my NHS treatment

Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Town/CityState / Province

Postcode
Mobile Phone*
Home Phone
Email
example@example.com
Please select any conditions that apply to you:

Rheumatic feverPacemakerEpilepsyDiabetesHeart problemsLiver or Kidney diseaseAsthmaHeart murmurJaundiceChest problemsHigh blood pressureHepatitisHayfeverBleeding disorderHeart surgeryBlackouts/ Fainting attacks/ GiddinessAny tablets for cancer or osteoporosisBad reaction to general anaestheticBad reaction to local anaestheticHospitalised for any operations/serious conditions in last 5 yearsTaken steroids in last 2 yearsDo you carry a warning cardAre you seeing a doctor at presentHad a joint replacedHave used needle delivered recreational drugsI have ALLERGIESI take pills/medications
I have these allergies:
I take these pills/medication:
If female, are you or do you think you may be pregnant?*
If you smoke, how many cigarettes do you smoke per day?
If you smoke, how many years have you smoked for?
How many units of alcohol do you drink per week?
How many times per day do you brush your teeth?*
Do you brush your teeth with fluoride toothpaste?*
How often per week do you floss your teeth?
Name and address of your Doctor:*
Have you tested positive for COVID-19 in the last 7 days?*

YesNo
Are you waiting for a COVID-19 test or the results?*

YesNo
Do you live with someone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days?*

YesNo
Do you have any of the following symptoms:

New, continuous cough*;High temperature or fever;Loss of, or change in, sense of smell or taste?
* A new, continuous cough means coughing for longer than an hour, or
three or more coughing episodes in 24 hours. If the patient usually has a
cough, it may be worse than usual.

If you have answered YES to any of the above, you should not attend the practice.

If you have recovered from COVID-19, or completed a period of self-isolation, you are able to attend the practice.

A person is considered to have recovered from COVID-19 infection when
they meet all of the following criteria:
• It has been at least 7 days since the onset of the COVID-19 symptoms;
• They no longer have a high temperature.
N.B. A cough may persist for several weeks in some people, even though the coronavirus infection has cleared. The loss of, or change in, sense of smell or taste may also linger. According to the CMO letter (18 May 2020) a person with a persistent cough and/or loss of sense of smell or taste but no other symptoms does not need to continue to self-isolate for more than 7 days.

I hereby declare that the information provided is complete and accurate. I fully understand that any false information can put the healthcare workers attending to me at a higher risk of contracting COVID-19 disease. I fully agree to follow all the instructions regarding precautionary steps by the treating clinician and staff at the clinic.
I am visiting the clinic with full knowledge that we are going through a COVID-19 global pandemic.
There is always a risk of contracting this virus when I am visiting a place during this pandemic.
There is a possible risk of getting this virus by visiting any place during this pandemic. I have been fully explained the content of this declaration form in a language that I can understand.
I hereby absolve the treating clinician and the team members of Royston Dental Practice / freshfaced of any criminal or medicolegal liability arising due to my visit to the clinic. I hereby give my consent for this.
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