Wickham Dental Patient COVID-19 Screening Form

Wickham Dental Patient COVID-19 Screening Form
Due to COVID we are unable to use our waiting room. Please attend your appointment with appropriate clothing to wait outside, or wait in your car with a mobile phone we can use to call you when the room is ready. Please use the toilet and brush your teeth at home before attending. We apologise for any inconvenience caused. visiting-wickham-dental-during-the-coronavirus-pandemic
Name *

First Name Last Name
Email
example@example.com
Date of Birth *

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

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. If you answer "yes" to any of the questions, we respectfully request that you reschedule you appointment.

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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