Covid-19 Screening Form
Please complete ALL fields, and return the day before your appointment
Patient's name: -
*
First Name
Last Name
Email
*
example@example.com
Mobile Number
*
Date of Birth
*
/
Day
/
Month
Year
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1. Do you have any of the following symptoms:-
High temperature or fever?
*
Yes
No
New continuous cough?
*
Yes
No
A loss or alteration to taste or smell?
*
Yes
No
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2. Have you or any member of your household/family had a confirmed diagnosis of COVID-19 in the last 10 days?
*
Yes
No
3. Are you or any member of your household/family waiting for a COVID-19/SARS-CoV-2 PCR test result?
*
Yes
No
4. Have you travelled internationally in the last 10 days to a country that is on the government red list?
*
Yes
No
5. Have you or any member of your household/family been advised to isolate yourself by any NHS organisation in the last 10 days?
*
Yes
No
Additional information:-
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I would like to be kept informed of developments, offers and other marketing activities via e mail by Owlsmoor Dental Practice:-
Yes
No
Signature
*
Please draw signature with mouse or finger
Date
-
Day
-
Month
Year
Date
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