When you come to the practice, please disinfect your hands with the sanitiser provided and please wear a mask either your own or one we will provide. With social distancing requirements, we can only seat four 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 only be a PPE fee, if surgical gowns are required.

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

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

Your Name (required)

Date of Birth (required)

Your Email (required)

Mobile Number (required)

Home Number

Name of GP (required)

GP Telephone Number (required)

Address of GP (required)

Next of Kin (required)

Next of Kin Telephone Number (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; 
 

I consent for The White House Dental Surgery 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 

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