Covid-19 Screening Online Please complete your safety check 24-48 hours before your appointment. Covid-19 Screening Faces & Smiles Appointment Date* Date Format: MM slash DD slash YYYY Practice Location*F&S Norwich (Sainsbury’s)F&S Gt YarmouthF&S LowestoftFull Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Email* Mobile*Do you or anyone living with you have: 1. A high temperature 37.8 degrees (means hot to touch on chest/ back), 2. a new continuous cough, 3. a sudden loss of taste or smell?*NoYesHave you come into close contact (6ft/2m) with someone diagnosed with coronavirus in the past 14 days?*NoYesAdditional COVID information S,V,L,None* Shielding (high risk) Vulnerable (moderate risk) Lives with someone in the above groups None of the above Your MessageThe practice can send email communication about treatment to your device. With your help we aim to go paperless. I agree to the practice sending me email and text**.Email communication about treatment includes appointment times, receipts, dental reports, etc. sent directly to your computer and mobile phone.** Selected practice has text options for your mobile phone. Please your contact details updated and accurate. With your help, we can be more eco-friendly.CAPTCHANameThis field is for validation purposes and should be left unchanged.