Forms to fill in

Please wear your mask when attending

Covid-19 Screening Form

Medical History Form

 
Doctor Taking Notes

Medical History Form

Confidential Form

This is a medical history form that will form part of your clinical notes. Only once you have had an examination and seen the dentist you are registered.

Do you suffer from any of the following medical problems:- (please click those that apply to you)

Thanks for submitting!

 
Covid-19.jpeg

Covid-19 Health Screening Form

Confidential screening form to be completed no earlier than the day before attending Jct 20 Dental Clinic

Please provide details of your health related to Covid-19.

Do you have a high temperature/ Fever?
Do u have a new continuous cough?
Have you experienced a loss of your normal sense of taste or smell?
Have you or any member of your household/family had a confirmed diagnosis of COVID-19 in the last 10 days?
Are you or any member of your household/family waiting for a COVID-19 PCR test result?
Have you travelled internationally in the last 10 days to a country that is on the government red list?
Have you or any member of your household/family been advised to isolate by any NHS organisation in the last 10 days?

Thanks for submitting!