COVID-19 Health Declaration

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We are collecting personal data of visitors to our practice for the purposes of enabling us
to carry out contact tracing and other response measures, in response to any emergency
that may arise due to COVID-19 that may threaten the life, health or safety of other individuals.

We have the right to refuse entry to any persons who are unwell, who have been to
locations of public health concern in the past 14 days or who have been in contact with any
person with a confirmed case of the coronavirus.

Name *

Email *

Phone number *

Visit Date *

JJJJ

Have you had fever, cough, or shortness of breath during the past 14 days? (for those who had taken medications, please answer “Yes”) *

Yes

a high temperature – this means you feel hot to touch on your chest or back (you do not need to measure your temperature)

a new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual)

a loss or change to your sense of smell or taste – this means you've noticed you cannot smell or taste anything, or things smell or taste different to normal

Does anyone in your household have a new, continuous cough or a high temperature? or has tested positive for corona virus? *

Yes

If Yes, are you still in the self/household isolation period?

Yes

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Have you ever had any disease or treatment as below? *

Cancer

Chemotherapy

Radiotherapy

Diabetes

Heart Disease

Lung Disease

N/A

I have answered all questions to the best of my knowledge. *

Yes

I acknowledge and agree to Dentexcel, use and disclosure of my personal data, health information and recent travel history for the purposes set out in this Form. *

Yes

If there is any information we ought to know, please write below:

Senden

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