Covid-19 Self Assessment Form

We ask you to complete the Covid-19 Self Assessment form below on the evening before your dental appointment (but no more than 24 hours beforehand). If we do not receive a completed form by 8pm then we will not be able to see you the following day.

Your responses will of course be treated in confidence. If you do answer yes to any of the questions we would ask that you do not attend the practice and follow Government advice regarding self isolation. Please phone or email us when you are able to and we will re-schedule your appointment.

Having filled in the assessment form, should you be taken ill with COVID-19 symptoms on the day of your appointment, please do not attend. Please let us know of your change in condition by phoning the practice on 01442 865646.

COVID-19 Self Assessment Form

  • DD slash MM slash YYYY
  • :
    *Coughing continuously for an hour or more 3 times (or more) in the past 24 hours
  • This field is for validation purposes and should be left unchanged.