COVID-19 Health Declaration
We are collecting personal data of visitors to our practice for the purposes of enabling us
to carry out contact tracing and other response measures, in response to any emergency
that may arise due to COVID-19 that may threaten the life, health or safety of other individuals.

We have the right to refuse entry to any persons who are unwell, who have been to
locations of public health concern in the past 14 days or who have been in contact with any
person with a confirmed case of the coronavirus.
Name *
Email *
Phone number *
Visit Date *
MM
/
DD
/
YYYY
Have you had fever, cough, or shortness of breath during the past 14 days? (for those who had taken medications, please answer “Yes”) *
Does anyone in your household have a new, continuous cough or a high temperature? or has tested positive for corona virus? *
If Yes, are you still in the self/household isolation period?
Clear selection
Have you ever had any disease or treatment as below? *
I have answered all questions to the best of my knowledge. *
I acknowledge and agree to Dentexcel, use and disclosure of my personal data, health information and recent travel history for the purposes set out in this Form. *
If there is any information we ought to know, please write below:
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy