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




had contact with somebody with Coronavirus,




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.





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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)

Do you suffer from high blood pressure? (required)

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

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

Do you suffer from epilepsy? (required)

Ladies only, are you pregnant? (required)

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

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

If yes, please give details;

Do you have any allergies? (required)

If yes, please list here;

Do you suffer from any heart problems (required)

If yes, please give details;

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

If yes, please give details;

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

If yes, for what reason;

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

If yes, please give details;

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

If yes, please list here;

Do you smoke any tobacco products? (required)

If yes, number per day;

I consent for The White House Dental Surgery to send me reminders by Text message and or email:

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


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