First Name (required)
Surname (required)
Contact Email (required)
Do you have a confirmed diagnosis of COVID-19? (required) YesNo
Have you or any member of your household had COVID-19 in the last 7 days? (required) YesNo
Are you required to self-isolate? (required) YesNo
Do you have ANY of the following symptoms now, or in the last 7 days: fever, acute cough or shortness of breath; muscle aches, loss of smell, sore throat; generally feeling unwell with no other likely diagnosis? (required) YesNo
Do you have any other reason to think that you are at risk of having COVID-19? (required) YesNo
I understand that Shakespeare Orthodontics has set up their practice to reduce the risk of contracting COVID-19 according to the joint Ministry of Health and Dental Council guidelines. I have opted to attend my orthodontic treatment appointment on my own accord, and am aware of the risks of contracting COVID-19 in such a public place despite these best practice precautions. (required)
