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COVID19 QUESTIONNAIRE

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

Name *

Email Address *

Date of Birth *

Phone *

Have you had any of the following new symptoms in the past 48 hours? *Temperature greater than 37.5 CSudden loss of smell or/and tasteMuscular achesUnexplained tiredness of lethargySore throatCoughShortness of breath or difficulty in breathingAny symptoms of respiratory tract illnessCold or flu-like symptomsDiarrhoeaI have not had any of the above

Please select any of the following scenarios which apply to you? *Are you currently unvaccinated against Covid-19?Have you been in contact with a confirmed case of Covid-19 in the past 14 days?Have you shown any symptoms associated with Covid-19 in the past 14 days?Have you tested positive for Covid-19 in the past 14 days?Has any household member tested positive for Covid-19 in the last 14 days?Are you or a household member currently awaiting a test result for Covid-19?Are you currently isolating due to Covid-19 symptoms?Do you have a household member who is currently isolating due to Covid-19 symptoms?Have you returned from travelling within the last 14 days?Are you living in a residential care facility?None of the above scenarios apply to me

Based on your activity over the last 14 days, how would you subjectively classify your risk of being exposed to or infected by COVID-19? *

HOW DID WE DO?

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