COVID 19 Pyes Pa 2021 Please fill out this form and submit before EVERY visit to our practice. NAME* E MAIL* PHONE NUMBER Vaccination status First dose only Fully vaccinated and valid vaccine pass Un-Vaccinated At ER Dental we want to help our vaccinated as well as un-vaccinated patients. Please let us know your status and we can book you in the correct time slot. NOTE: This is only for new appointments going forward and will not affect any existing appointmentsDo you have a confirmed diagnosis of COVID-19?* YES NO Are you waiting for a COVID-19 tes or the results, or considered a probable case or been asked to self-isolate?* YES NO Have you, or anyone living with you had contact with someone with a confirmed or suspected diagnosis of COVID 19in the past 14days? 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 Overseas travel Have your travelled overseas in the last 14 days and been required to quarantine since your arrival in New Zealand? YES NO Have you had direct contact with someone in the last 14 days who has travelled overseas and been required to quarantine since their arrival in New Zealand? YES NO Do you work on an international aircraft or shipping vessel? YES NO Do you work or have you recently worked in customs, immigration,or at managed quarantine/isolation facilities. YES NO Are you a household member or a commuinty contact of aircrew? YES NO Less frequent symptoms. Do you have less typical symptoms such as: Fever only Diarrhoea Headache Myalgia Nausia/vomitting CAPTCHA
