COVID-19 Screening & Consent Personal detailsFull Name* Please SelectMrMrsMissMsDrProf.Rev. Prefix First Last Date of Birth* DD slash MM slash YYYY Sex* Male Female Address* Street Address Address Line 2 City ZIP / Postal Code Mobile number*Home numberEmail* Enter Email Confirm Email COVID-19 Patient Screen FormHave you had COVID 19?* Yes No Have you been tested for COVID 19?* Yes No Do you have fever or have you felt hot or feverish recently (14-21 days)?* Yes No Do you having shortness of breath or other difficulties breathing?* Yes No Do you have a cough?* Yes No Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?* Yes No Have you experienced recent loss of taste or smell?* Yes No Are you 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)* Yes No Is your age over 60?* Yes No Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?* Yes No Have you travelled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)* Yes No Positive responses to any of these may involve a deeper discussion with your dentist before proceeding with elective dental treatment or scheduling your appointment appropriately. Patients with conditions such as heart disease, high blood pressure, diabetes, obesity, or who are older than 60 or from a BAME group may have a higher risk at this time.Consent COVID-19* I consent to the treatment being provided during the current phase of Covid-19.I am aware that the current COVID-19 pandemic brings several known and unknown risks. I understand the virus has a long incubation period during which time carriers of the virus may not show symptoms yet still be highly infectious. I understand during dental treatment social distancing cannot be maintained but the dental practice will use strict cross infection control and suitable PPE. I voluntarily assume all medical/dental risks, which may be associated with my treatment during this time. I acknowledge that the nature and purpose of the dental procedures recommended under the current circumstances and restrictions have been explained to me and that I have been given the opportunity to ask questions. Signature*Signature COVID-19EmailThis field is for validation purposes and should be left unchanged.