Forms to fill in

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:
 
Statue with Mask

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.

Have you ever been diagnosed with coronavirus?
Do u have a cough? or a new persistent dry cough in the last 14 days?
Do you have a high temperature/ Fever?
Have you experienced a loss of your normal sense of taste or smell?
Do any of the following apply to you?
 

0161 740 5407

1190 Rochdale Rd. Blackley. Manchester United Kingdom. M9 6FR

©2018 by JCT 20 Dental Clinic.