Covid Screening & the Practice Information

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?

Are you/the patient have a swollen tongue, small red or white bumps and unusual mouth ulcers?

Is your/the patient age over 70?

Have you had the Covid-19 vaccine?

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 red listed countries?

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

Name/relation

The Practice Information

On the day of the appointment please arrive at your appointment time.

Please enter with your face mask on.

If waiting outside please keep to social distancing guidelines.

Please re-confirm you/the patient is still symptom-free at your appointment before entering.

You will be met by the nurse who will have a face mask.

You will be asked to sanitise your/patient’s hand.

The dental practice is equipped with a ventilation system with no air recirculation ensuring fresh air at all times.

We will send your routine check-up appointment by SMS or email.

Thank you,

Kind regards, Reception Team

Willerby Dental Care, 81 Kingston Road, Willerby, HU10 6AH

www.willerbydentalcare.co.uk, info@willerbydentalcare.co.uk, SMS 07817176134