Online Covid Screening Questionnaire

15 Gray Street, Ipswich QLD 4305

07 3202 3999

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About Us
Kids
- Kids Treatment Room
- Free Kids Dental
Services
Before & After
Blog
Health Form
Contact
Online Booking

About Us
Kids
- Kids Treatment Room
- Free Kids Dental
Services
Before & After
Blog
Health Form
Contact
Online Booking

COVID Screening Form

So we can ensure we are looking after your needs, please review and complete the following questionnaire.

Title: Mr/Mrs/Miss/Ms/Dr:

Surname:

First Name:

Have you been feeling unwell?

Yes No

Have you had any of the following symtoms?

Fever or temperature now or in the past 3 days? Sore throat, cough or shortness of breath? Runny stuffy nose or other respiratory symtoms? Loss of smell or taste?

Have you, or a person with whom you live, been asked to quarantine due to:

Attending an area identified as high risk for community transmission? Interstate or international travel

Have you, or a person with whom you live, been asked to self-isolate while waiting for COVID-19 test results?

Yes No

Are you, or a person with whom you live, an essential worker who is travelling interstate?

Yes No

Consent for treatment

By checking this box you agree to a pre procedural mouth rinse?

Social Distancing

Due to social distancing requirements, you agreee to one support person when required?

*** Please ensure you wear a mask to your appointment ***

Trading Hours

Mon – Wed – Fri: 8.30am to 5pm
Tue – Thu : 9am to 8pm
Sat: 8am to 12pm

Address

15 Gray Street,
Ipswich QLD 4305

Phone

07 3202 3999

Payment Options

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COVID Screening Form

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