Omokoroa dental Covid-19 form

Please fill out this form and submit before EVERY visit to our practice.

NAME*
E MAIL*
PHONE NUMBER
Do you have a confirmed diagnosis of COVID-19?*
- YES
- NO
Have you, or anyone living with you had contact with someone with a confirmed or suspected diagnosis of COVID 19?
- YES
- NO
Have you, or anyone living with you returned from overseas in the last 14 days?
- YES
- NO
Do you, or anyone living with you have the following symptoms;
- Sore throat
- Cough
- Shortness of breath
- High fever
- Any other symptoms of illness