Confidential Medical History Form
Have you tested positive for COVID-19 in the last 14 days?
Do you CURRENTLY have any of the following symptoms:
A raised temperature or fever? (Feel hot to touch on your chest/back)
A new continuous cough? (1hr recurrently or 4+ episodes/24hr)
Partial/total loss of your sense of smell or taste?
A runny nose or sore throat?
Shortness of breath or breathing difficulties?
Are you, or anyone within your household currently within a 10-day isolation period?
Have you had two COVID-19 vaccinations?
Are you in a vulnerable group or at increased risk of serious illness from COVID-19?
(If Yes please add details)
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: