Covid-19 Questionnaire

Ainsty Dental

Please complete the form  below before your upcoming appointment. If attending as a family please submit a separate form for each individual member. If you have attended the practice within the last 2 weeks you do not need to submit an additional form.

    Have you been diagnosed with Coronavirus?

    Do you have a fever or have you/they felt feverish recently (14-21 days)?

    Are you having shortness of breath or other difficulties Breathing?

    Do you currently have a cough? or have you had a persistent dry cough in the last 14 days?

    Do you have any other flu like symptoms, such as gastrointestinal upset, headache or fatigue?

    Have you experienced a loss of taste or smell?

    Are you in contact with any confirmed Covid-19 positive patients?

    Have you travelled in the past 14 days to any regions affected by Covid-19?

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

    Are you 70 years old or above?