E-Consultation

COVID19 QUESTIONNAIRE

All patients are required to complete each and every question. It is vitally important that all patients attending TwentyOneDental complete this section at least 3 days before attending the clinic for an appointment. Failure to do so will result in your appointment being cancelled, charged for and entry to the clinic not permitted.

Firstly, we need to know who you are. We then need you to re-confirm your email and mobile number:



    • Should you not have an email address please contact the clinic on

01273 202102

    • immediately.

Now please carefully read the following and each and every question before answering:


  • Have you been in communication with someone who may have COVID-19 (coronavirus) infection or had any of the following recently? Please tick all that apply. (required)

  • I have been in contact but I am asymptomatic
  • Persistent cough
  • Shortness of breath or difficulty breathing
  • Temperature above 37.8 degrees
  • Any symptoms of respiratory tract illness whatsoever
  • Loss of taste and / or smell
  • Unexplained tiredness or lethargy
  • Muscular aches
  • I have not had any of the above
  • If you have responded positively to any of these symptoms, we would strongly advise self isolating and delaying non-essential care for at least one month. If you have a dental emergency please contact the practice on hello@twentyonedental.co.uk so that we may make special arrangements for your emergency care.

    Based on your activity over the last 4 weeks, how would you subjectively classify your risk of being exposed to or infected by COVID-19? (required)

  • High risk – Frontline health care worker or confirmed case of infection at home
  • Moderate risk – Key worker in contact with public but without symptoms or known exposure to an infected individual
  • Low risk – Have been isolated / in lockdown alone or with family members with minimal social contact and no known exposure to an infected individual
  • Previously infected and recovered – Confirmed by hospital testing with documentation (please bring documentation with you when attending)

Visit Us

TwentyOneDental,
21 New Church Road,
Brighton, & Hove BN3 4AD

Call Us

01273 202 102

Email Us

hello@twentyonedental.co.uk

Visit Us

TwentyOneDental,
21 New Church Road,
Brighton, & Hove BN3 4AD

Call Us

01273 202 102

Email Us

hello@twentyonedental.co.uk