Covid-19 Form

For submission to us before treatment

COVID-19 Screening

Please answer the following questions.  If you are unsure of how to answer any of the questions, please contact us on 01228 528022 to discuss.

Patient Enquiry Form

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If you answered ‘yes’ to any questions please supply details in ‘notes’ below.

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If you are not sure of any of the questions, or if your medical circumstances change, please inform The Dental Surgeon.

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Please enter your email address
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Risk Information

High Risk Individuals

  • have had an organ transplant
  • are having chemotherapy or antibody treatment for cancer, including immunotherapy
  • are having an intense course of radiotherapy (radical radiotherapy) for lung cancer
  • are having targeted cancer treatments that can affect the immune system (such as protein kinase inhibitors or PARP inhibitors)
  • have blood or bone marrow cancer (such as leukaemia, lymphoma or myeloma)
  • have had a bone marrow or stem cell transplant in the past 6 months, or are still taking immunosuppressant medicine
  • have been told by a doctor they have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD)
  • have a condition that means they have a very high risk of getting infections (such as SCID or sickle cell)
  • are taking medicine that makes them much more likely to get infections (such as high doses of steroids or immunosuppressant medicine)
  • have a serious heart condition and are pregnant

Moderate Risk (clinically vulnerable)

  • are 70 or older
  • are pregnant
  • have a lung condition that's not severe (such as asthma, COPD, emphysema or bronchitis)
  • have heart disease (such as heart failure)
  • have diabetes
  • have chronic kidney disease
  • have liver disease (such as hepatitis)
  • have a condition affecting the brain or nerves (such as Parkinson's disease, motor neurone disease, multiple sclerosis or cerebral palsy)
  • have a condition that means they have a high risk of getting infections
  • are taking medicine that can affect the immune system (such as low doses of steroids)
  • are very obese (a BMI of 40 or above)

Lismore House Dental in Carlisle

Lismore House,
Lismore Street, Carlisle, CA1 2AH
T: 01228 528022
www.lismoredental.co.uk

Mark Fortune B.D.S. 113720
Rebecca Fortune B.D.S. 113722
Lismore Care Ltd. 10292404
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