Form B-Patient Screening Form COVID19


    Do you/they have fever, or have you/they felt hot or feverish recently (14-21 days)?

    YesNo


    Are you/they having shortness of breath or other difficulties breathing?

    YesNo


    Do you/they have a cough?

    YesNo


    Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

    YesNo


    Have you/they experienced a recent loss of taste or smell?

    YesNo


    Are you/they in contact with any confirmed COVID-19 positive patients?
    Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

    YesNo


    Is your/their age over 70?

    YesNo


    Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

    YesNo


    Have you/they traveled in the past 14 days to any region affected by COVID-19?

    YesNo


    Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with dental treatment.


    Please select the clinic: