Parent / Carer Covid Risk Assessment | Singleton Dental Practice & Implant Centre

Parental or Carer Covid-19 Risk Assessment

Please complete the following questions for risk assessment and consent prior to attending Singleton Dental.

Your answers will be recorded in the dental records of your child/caree/client held by Singleton Dental to show you were present during the appointment.

Your record may also be used by UK Government Test and Trace in relation to Covid 19 if necessary.

Name *

Date of birth *

Address *

Phone *

Email *

Do you or anyone in your household currently have covid 19? *

Do you have a new, continuous cough? *

Do you have a high body temperature (37.8C or above) ? *

Do you have a loss of, or change in, your normal sense of taste or smell? *

Does anyone in your household have a new continuous cough, a high temperature, or altered sensation of taste or smell? *

Are you or any member of your household self isolating as a result of possible or confirmed COVID-19 infection? *

Name of the child or vulnerable adult you are acting as carer for? *

Do you hold parental responsibility for the above person? *

If no, please state in what capacity you are acting as a carer.

Consent to visiting Singleton Dental as a carer during the COVID-19 pandemic: I am aware that the current COVID-19 pandemic brings a number of known risks and a number of unknown risks. I have freely chosen to act as a carer for someone attending for dental treatment during the pandemic in the knowledge that much is still unknown about the virus. I understand the coronavirus that causes COVID-19 has a long incubation period during which time carriers of the virus may not show symptoms yet still be highly contagious. I also understand that some people may have the virus but may not ever have any symptoms. I therefore understand it is impossible to determine who has the virus and I understand that I must assume that anyone anywhere could be infected and infectious. *

I confirm my consent.

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SINGLETON DENTAL PRACTICE

Dental Implants, Orthodontics & Aesthetics

Tel: 01233629516

Parental or Carer Covid-19 Risk Assessment