Wickham Dental Practice

Wickham Dental Practice

Patient COVID-19 Screening Form
Due to COVID we still have measures in place to protect out patients and staff. Please attend your appointment on time, or wait in your car with a mobile phone we can use to call you when the surgery is ready. Please see our website visiting-wickham-dental-during-the-coronavirus-pandemic
Name *

First Name Last Name
Date of Birth *

Day Month Year
Date
Email
example@example.com
Mobile Phone Number for contact while waiting for your appointment *
Have you had a COVID-19 vaccination *

Yes No
Have you tested positive for COVID-19 in the last 10 days? *

Yes No
Do you have or have you had, in the last 14 days a new, continuous cough or respiratory problem, high temperature or fever, altered smell or taste? *

Yes No
Are you currently quarantining or self-isolating after travel? *

Yes No
Have you been notified by NHS test and trace in the last 14 days that you are a contact of a person who has tested positive for COVID-19? *

Yes No
Emergency Name and Phone Number
Signature *

Clear
Date *

Day Month Year
Date
By signing and submitting, I confirm that the information I have given is true, and that I am fit and healthy to attend Wicham Dental Practice.

All information given will be treated confidentially. Wickham Dental Practice will will keep the information collected safely. Any personal information will not be disclosed unless as required by law, or with your express consent.
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