Due to Covid-19 requirements, please fill in the following forms prior to attending an appointment at the practice. If you have any questions please get in touch. Thank you.

    Consent to dental treatment during COVID-19


    I, , knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.

    I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.

    All dental procedures create water spray(aerosol) which is how the disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.

    • I understand that due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental practice.

    I confirm that I am not currently suffering from any of the following symptoms of Covid-19 and I have not suffered from any of these symptoms in the last 7 days

    • Fever (a temperature of 37.8 degrees centigrade or above).
    • A new persistent dry cough.
    • Muscle pains.
    • Headache.
    • Shortness of breath and breathing difficulties.
    • Severe pneumonia.
    • Loss of taste and/or smell.
    • Extreme fatigue.
    • Runny nose.
    • Sore throat

    I confirm that I have not been in close contact (within 2 metres) of anyone suffering with any of these symptoms in the last 14 days

    I understand that receiving dental treatment means that the UK government’s instruction to maintain social distancing of at least 2 metres is not achievable during treatment

    I consent to the treatment being provided during the current lockdown phase of Covid-19

    Email address:
    Mobile phone number:

     

    Confidential Medical History Form

    Personal details
    Title
    First Name
    Surname
    Your Address

    Postcode
    Date of Birth
    Gender
    Occupation
    Tel No
    Mobile
    Work No
    Email Address
    When did you last receive dental treatment?
    Your G.P Name and Address


    Next of Kin Details
    Name and Contact Number

    Relationship to you

     


    Have you tested positive for COVID-19?
    YesNo
    Have you a raised temperature or fever? (Feel hot to touch on your chest/ back)
    YesNo
    Do you have a new continuous cough? (1hr recurrently or 4+ episodes/24hr)
    YesNo
    Do you have partial/total loss of your sense of smell or taste?
    YesNo
    Have you been isolating with symptoms in the past 14 days?
    YesNo
    Are you or the household self-isolating?
    YesNo
    Have you been in contact or does anyone in your household exhibit any flu like symptoms?
    YesNo
    Are you in a vulnerable group or at increased risk of serious illness from COVID-19?
    YesNo
    Are you currently attending or receiving treatment from a doctor, hospital or specialist?
    YesNo
    Are you pregnant or a nursing mother?
    YesNo
    Are you currently taking any prescribed medicines, tablets, drugs or injections or using any creams, ointments or inhalers?
    YesNo
    Are you carrying a medical warning card?
    YesNo
    Do you suffer from allergies to any medicines, food, substances or materials? (e.g. Penicillin, Latex/Rubber)
    YesNo
    Do you suffer from hay fever or eczema?
    YesNo
    Do you suffer from asthma, bronchitis or other chest conditions?
    YesNo
    Do you suffer from fainting attacks, giddiness, blackouts or epilepsy?
    YesNo
    Do you suffer from heart problems, angina, blood pressure problems or stroke?
    YesNo
    Are you a diabetic (or is anyone in your family)?
    YesNo
    Do you suffer from arthritis?
    YesNo
    Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery?
    YesNo
    Do you suffer from any infectious diseases, including HIV and hepatitis?
    YesNo
    Are you HIV positive?
    YesNo
    Have you ever had rheumatic fever or chorea?
    YesNo
    Have you ever had liver disease (e.g. jaundice, hepatitis) or kidney disease?
    YesNo
    Have you ever had any other serious illness?
    YesNo
    Have you ever had your blood refused by the Blood Transfusion Service?
    YesNo
    Have you ever had a bad reaction to local or general anaesthetic?
    YesNo
    Have you ever had a joint replacement or other implant?
    YesNo
    Have you ever had treatment that required you to be in hospital?
    YesNo
    Have you ever had heart surgery or do you have a pace maker?
    YesNo
    Have you ever had brain surgery?
    YesNo
    Did you receive growth hormone treatment before the mid 1980’s?
    YesNo
    Do you have any close relatives with Creutzfeldt Jakob Disease?
    YesNo
    Are you taking or have you ever taken Alendronic Acid or Bisphosphonates?
    YesNo
    On average how many units or alcohol do you consume per week?
    YesNo
    Do you smoke any cigarettes? (if so, how many per day)
    YesNo
    Do you smoke or chew any tobacco products, pan, use gutka or supari?
    YesNo
    Is there any other information which your dentist might need to know about, such as self-prescribed medications? (i.e. Aspirin)
    YesNo

     



    Consent
    DentalHouse will never give your information to a third party for marketing purposes. We will only share relevant information from your dental records with other professionals when clinically required, for example when we need to refer you to hospital or specialist services.

    To indicate consent please enter the following details:
    Name
    Status
    Date of Birth

     

    You must fill in all fields AND consent to all the above to be able to send these forms.

    If you are having any difficulties completing this form please get in touch.