Wickham Dental Practice

Wickham Dental Practice

Patient and accompanying adult/ carer COVID-19 Screening Form
PLEASE COMPLETE THIS FORM FOR THE PATIENT ATTENDING AND ANY CARERS/ PARENTS/GUARDIANS ATTENDING WITH THE PATIENT.

For further details on visiting us see visiting-wickham-dental-during-the-coronavirus-pandemic
Name *

Last Name
Name

First Name Last Name
Date of Birth *

Day Month Year
Date
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
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 an 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
Have you travelled internationally and are waiting results of your PCR test? *

Yes No
Have you had your COVID-19 vaccination? *

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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