Online Pre-screening - Notting Hill Dental Clinic

Personal details

Name*

Prefix First Last

Date of Birth*

Mobile*

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City Country

COVID-19 Patient Screen Form

Have you tested positive for COVID - 19 in the last 7 days?*

Yes
No

Are you waiting for a COVID - 19 test or the results?*

Yes
No

Do you have any of the following symptoms:*

NO
New, continuous cough
High temperature or fever
Loss of, or change in, sense of smell or taste?

Do you live with someone who has either tested positive for COVID - 19 or had symptoms of COVID - 19 in the last 14 days?*

Yes
No

Have you been notified by NHS Test and Trace in the last 14 days that you are a contact of a person who has tested positive for COVID - 19 and you do not live with that person?*

Yes
No

Have heart disease, lung disease, kidney disease, diabetes or any other auto - immune disorders?*

Yes
No

Are you pregnant?*

Yes
No

Are you or the patient aged 70 years old*

Yes
No

* A new, continuous cough means coughing for longer than an hour, or three or more coughing episodes in 24 hours. If the patient usually has a cough, it may be worse than usual.

Consent COVID-19*

please tick to confirm the information is correct

Signature*

Signature COVID-19

Date of Signature

Phone

This field is for validation purposes and should be left unchanged.

Online Pre-screening – COVID-19

Personal details

COVID-19 Patient Screen Form

* A new, continuous cough means coughing for longer than an hour, or three or more coughing episodes in 24 hours. If the patient usually has a cough, it may be worse than usual.