COVID 19 OMOKOROA DENTAL Please fill out this form and submit before EVERY visit to our practice. NAME*E MAIL*PHONE NUMBERDo you have a confirmed diagnosis of COVID-19?* YES NOHave you, or anyone living with you had contact with someone with a confirmed or suspected diagnosis of COVID 19? YES NOHave you, or anyone living with you returned from overseas in the last 14 days? YES NODo you, or anyone living with you have the following symptoms; Sore throat Cough Shortness of breath High fever Any other symptoms of illness