COVID-19 Form | Dentist In Kent

COVID-19

Name*
First Last
Email
Q1: Have you tested positive for COVID -19 in the last 7 days?*
- Yes
- No
Q2: Are you waiting for a COVID-19 test or the results?*
- Yes
- No
Q3: Do you have any of the following symptoms: New, continuous cough – high temperature or fever – loss of, or change in, sense of smell or taste?*
- Yes
- No
Q4: 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
Q5: 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
Consent COVID-19**
please tick to confirm the information is correct
Signature*
Signature Date
Date Format: DD slash MM slash YYYY
Name
This field is for validation purposes and should be left unchanged.