Coronavirus Procedure

When you come to the practice, please disinfect your hands on entering the premises. With social distancing requirements, we can only seat two people in the waiting room, at any one time.

 

We would request that you DO NOT use the toilet facilities, unless absolutely necessary.

 

When you are called to the surgery, we shall record your temperature, after which we shall ask you to mouth rinse.

 

We shall don the appropriate PPE for your treatment. There will be a PPE fee of £20 per visit.

 

Upon finishing treatment, please see the receptionist for payment of fees and to make any further appointments.

 

When leaving the practice, please follow the exit signs to the rear of the building and on to the side alley.

 

Please rest assured, we are doing everything in our power, to provide you with safe and effective treatment. We ask for your patience at this very difficult time.

 

 

Have you been to an affected place in the last 14 days

 

or

 

had contact with somebody with Coronavirus,

 

and

 

do you have any of these symptoms?

 

Cough          Fever

 

Shortness of breath

 

Loss of smell or taste

 

If yes, to protect yourself and others please go home and call NHS 111 for expert advice. Please do not come to the practice.

 
 

 

Questionnaire

 

All required boxes MUST be completed

 
I hearby declare that I do not display any of the above symptomsAccepted

Your Name (required)

Date of Birth

Your Email (required)

Mobile Number. No spaces between numbers (required)

Home Number. No spaces between numbers

Name of GP (required)

GP Telephone Number. No spaces between numbers (required)

Address of GP (required)

Next of Kin (required)

Next of Kin Telephone Number. No spaces between numbers (required)

Do you suffer from headaches? (required)
YESNO

Do you suffer from high blood pressure? (required)
YESNO

Do you or any close relative suffer from diabetes? (required)
YESNO

Did you have rheumatic fever as a child? (required)
YESNO

Do you suffer from epilepsy? (required)
YESNO

Ladies only, are you pregnant? (required)
YESNO

Do you have any reason to suspect you may carry HIV, hepatitis B or C? (required)
YESNO

Do you have any chest/lung problems? (required)
YESNO

If yes, please give details;

Do you have any allergies? (required)
YESNO

If yes, please list here;

Do you suffer from any heart problems (required)
YESNO

If yes, please give details;

Have you ever been admitted to hospital for any operations or observations? (required)
YESNO

If yes, please give details;

Have you had a blood test for any reason in the last 15 years? (required)
YESNO

If yes, for what reason;

Do you suffer from any other medical condition? (required)
YESNO

If yes, please give details;

Are you taking any medication prescribed by a doctor or specialist? (required)
YESNO

If yes, please list here;

Do you smoke any tobacco products? (required)
YESNO

If yes, number per day;

Do you drink alcohol? (required)
YESNO (one unit is half a pint of beer, a single measure of spirits or a small glass of wine)

If yes, number of units per week;

I consent for Hillcross Dental Practice to send me reminders by Text message and or email:
YESNO

I consent to be given details of my appointment times, planned treatments and costs Accepted

I understand a fee will be charged if an appointment is broken or cancelled without 2 working days notice. Accepted

Personal details may be shared with the General Dental Council, Care Quality Commission, NHS, Dental payment plan administrators, Fraud prevention agencies or in the possible sale of the practice, to the purchaser of said practice Accepted

I understand I can withdraw my consent at any time Accepted

So that we can allocate sufficient time for your appointment, please indicate what the nature of your problem is, or what you would like us todo:

I consent to treatment Accepted

 

Find out more at nhs.uk/coronavirus