COVID-19 PRE-SCREENING QUESTIONNAIRE

For Confirmed Appointments Only

This questionnaire is intended only for patients who have a confirmed appointment time and is to be completed on the day of their appointment.

We are a registered NSW COVID-SAFE business. The safety and well-being of our patients and dental team are of utmost priority to us. Working together to help fight the spread of COVID-19 is important to us so that we can continue to bring you the optimum level of oral health care that you need.

As part of our precautionary measures during these challenging COVID-19 times, please kindly fill in the following pre-screening questionnaire PRIOR to your arrival on your appointment day. This will greatly assist us in ensuring that no one in the practice (patients, visitors and our employees) are exposed to potential virus risk while in our premises.

Thank you for your understanding and cooperation.

*Please refer to our Privacy Policy for details on how your personal information collected below is used within our practice.

Name

First Name

Last Name

COVID-19 PRE-APPOINTMENT DECLARATION

I CONFIRM THAT:

I have NOT TESTED POSITIVE for COVID-19 in the last 5 days and not required to be in self isolation..

I am not experiencing COVID-19 symptoms including cough, fever, sore throat, shortness of breath, runny nose, loss of smell and taste.

PLEASE CALL US ON (02) 4367-6222 TO DISCUSS A RESCHEDULE OF YOUR APPOINTMENT IF YOU ARE UNWELL WITH FLU-LIKE SYMPTOMS OR HAVE COVID-19. THANK YOU.

ADDITIONAL NOTES:

Appointment Date (Enter month-day-year)

YYYY

Signed by

Please type your name and it will be taken as your digital signature for the purposes of this online questionnaire.