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?
Have you been diagnosed with Coronavirus (COVID-19) recently?
*
Yes
No
OR
Have you been in close contact with a confirmed or probable case of Coronavirus (COVID-19)?
*
Yes
No
OR
In the last 14 days
Have you developed symptoms such as a fever, cough, sore throat, fatigue, or shortness of breath?
*
Yes
No
Have you travelled overseas or Interstate
*
Yes
No
OR
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
Submit
Should be Empty: