General Covid Form SimplyTeeth Essex, Online Consultation Form Thank you for choosing SimplyTeeth As part of our attempt to reduce contact time and decrease the rate of infection, we are asking all patients to prefill Covid Risk assessments and medical history forms. Please fill and sign and submit these secure forms so that they can be loaded onto your record cards before your visit. You may experience increased waiting times as we will try and minimise the amount of patients we see, and you may be asked for deposits in advance for the increased price of PPE to be done over the phone prior to your visit. Please help us to keep both you and Us safe. Please answer all questions. How did you hear about us? Full Name Date of Birth Address Contact Number Email Pre Visit Questions Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? YesNo Are you/they having shortness of breath or other difficulties breathing? YesNo Any other flu-like symptoms, such as stomach upset, headache or tiredness? YesNo Have you/They experinced recent loss of taste or smell? YesNo Are you/they in contact with any confimed COVID-19 positive patients?(Patients who have been positive or have family members who are sick should consider postpoing dental treatments) YesNo Is your/their age over 60? YesNo Have they travelled in the past 14 days to any region affected by COVID-19? YesNo Do you/they have heart disease,kidney disease, lung disease, diabetes, or any other auto-immune disorders? YesNo How can we help Are you happy with the colour of your teeth YesNo Have you ever thought of having your Silver/Mercury fillings replaced to white YesNo On a scale of 1-10 how happy are you with your smile (10 being very happy) If you could change one thing about your smile what would it be Have you ever thought of having your teeth straightened YesNo Have you ever thought of having your teeth whitened YesNo I confirm that all the information I have provided here is correct to the best of my knowledge and that I agree to the terms and conditions of SimplyTeeth Essex. This form is filled in by: Send SimplyTeeth Essex is featured in several media covers. Read more.