Willerby Dental Care

Covid-19 Screening Questionnaire

Please fill in and answer the following questions with either YES or NO. This must be completed 24 hours before your appointment. We may call you on the day of your appointment to reconfirm.

Your Name (required)

Contact Phone number

Your Email (required)

Have you/the patient felt hot or feverish recently (past 14 days)?

Are you/the patient having shortness of breath or other difficulties breathing?

Do you/the patient have a cough?

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Have you/the patient experienced a recent loss of taste or smell?

Are you/the patient in contact with any confirmed COVID-19 positive patients?

Are you/the patient well but have a sick family member at home with you?

Is your/the patient age over 70?

Are you/the patient in the shielded group?

Do you/the patient have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Have you/the patient traveled in the past 14 days to any regions affected by the government's quarantine requirement?

Please type below your name and relation if signing on behalf of the patient.

Name/relation