PATIENT SCREENING FORM
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Do you/they having shortness of breath or other difficulties breathing?
Do you/they have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Do you/they experienced recent loss of taste or smell?
Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
Is your/their age over 60?
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment. 

Please sign your name.

OPENING HOURS
Monday to Friday: 9:00AM to 5:00PM │Wednesday: 9:00AM to 7:00PM │Saturday: 9:00AM to 2:00PM
*Saturdays are prior to arrangement. We are closed over Bank Holiday weekends and between Christmas and New Year