Confidential Medical History Form
Have you tested positive for COVID-19?
Have you suffered 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?
Shortness of breath or breathing difficulties?
Headache or muscle pains?
Have you been in isolating with symptoms in the past 14 days?
Are you or the household self-isolating?
Have you been in contact or does your household exhibit any flu like symptoms?
Are you in a vulnerable group or at increased risk of serious illness from COVID-19?
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: