COVID-19 Questions

COVID-19 questions

Do any of the following questions apply to the person that is booking in for a dental appointment with Smile In Style?
In the last 7 days
Have you or anyone in the household been diagnosed with Coronavirus (COVID-19)? *

Yes No
OR
Are you currently experiencing symptoms of COVID such as a cough, fever, sore throat, shortness of breath or loss of sense of smell? *

Yes No
OR
Have you been in contact with a confirmed case of Coronavirus (COVID-19) in the last 7 days? *

Yes No
Have you been recommended to self–isolate or quarantine following advice from:-
National or state COVID-19 hotlines / A registered medical or nursing practitioner / COVID-19 trained health clinic triage staff *

Yes No
Who Signs? *

Patient Not the Patient
Signature

Clear
Patient Name *

First Name Last Name
Date *

Day Month Year
Date
Should be Empty: