Pre-Appointment Questionnaire

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This must be completed 2 days prior to our appointment. If things change between submitting the form and your appointment please contact the team on 020 79284474 or email: info@mintdentalclinic.co.uk.

By completeing this form you understand and agree to the following:

- I knowingly and willingly consent to have dental treatment completed during the COVID-
19 pandemic.

- I understand that any treatment provided by my dentist is intended to ONLY eliminate or
reduce the infection and/or pain that I am currently experiencing and may not be definitive care.
There may be a need for additional procedures to return the state of my mouth to optimum
health. Failure to seek additional treatment that my doctor recommends may result in further
issues, including pain, infection, and loss of teeth/bone and/or function.

- Due to the nature of this pandemic, I understand that any post-operative monitoring may
be needed to be performed remotely e.g. over telephone.

- I agree that, if I were to exhibit any symptoms of, or am diagnosed with, COVID-19, I will
immediately contact my dentist so that proper steps can be taken to limit the spread of this
contagion.

- I understand that the social distancing to prevent transmission of the virus is not possible within dental surgeries.

Email *

Full Name *

Date of Birth (dd/mm/yyyy) *

Address *

When is your appointment? (dd/mm/yyyy) *

• Do you or anyone in your household have/suspect you have COVID-19? *

Yes

Do you have a new, continuous cough? *

Yes

Do you have a high temperature (37.8oC or over)?

Yes

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Do you have a loss of, or change in, your normal sense of taste or smell? *

Yes

Does anyone in your household have a new, continuous cough, or a high temperature, or a loss of, or change in, their normal sense of taste of smell? *

Yes

If you or anyone in your household has, or has had, possible or confirmed COVID-19, are you still in the self/household isolation period? *

Yes

Are you shielding? (advised to stay indoors due to medical reasons) *

Yes

Do you believe you are at increased risk of severe illness from COVID-19 *

Yes

Not Sure

Please confirm you have read and understood our Arrival Etiquette Procedure (emailed to you)? *

Yes

A copy of your responses will be emailed to the address you provided.

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