Please only complete this form if you have been asked to

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

When you arrive for your appointment please wait in your car and call us to let us know that you have arrived.

Your temperature will be taken on arrival (if it is over 37.8 you will be sent home to reschedule)

We ask that you wear a face covering when travelling through the practice (unless you have a medical exemption), please bring minimal belongings with you and attend the appointment alone if possible.

    Confidential Medical History Form

    Personal details


    Full Name
    Date of Birth
    Email address
    Mobile phone number:

    Have there been any changes in your medical history? YesNo

    (If Yes please add details)

     


    Have you tested positive for COVID-19 in the last 14 days?
    YesNo


    Do you CURRENTLY have any of the following symptoms:

     

    A raised temperature or fever? (Feel hot to touch on your chest/back)

    YesNo

    A new continuous cough? (1hr recurrently or 4+ episodes/24hr)

    YesNo

    Partial/total loss of your sense of smell or taste?

    YesNo

    A runny nose or sore throat?

    YesNo

    Shortness of breath or breathing difficulties?

    YesNo

    Are you, or anyone within your household currently within a 10-day isolation period?

    YesNo

    Have you had two COVID-19 vaccinations?

    YesNo

    Are you in a vulnerable group or at increased risk of serious illness from COVID-19?

    YesNo

    (If Yes please add details)

     



    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

     

    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.