Choice Dental Covid-19 Screening Form COVID-19 Screening Declaration As part of the Queensland Government's Roadmap to keep businesses open and safe, it is a requirement to complete this questionnaire prior to your appointment. This questionnaire is to be completed by all patients regardless of vaccination status. This questionnaire is to be completed again at each and every dental visit (Effective 12th December 2021)Have you been feeling unwell?* YES NO Have you had any of the following symptoms?Fever or temperature now or in the past 3 days?* YES NO Sore throat, cough or shortness of breath?* YES NO Runny/stuffy nose or other respiratory symptoms?* YES NO Loss of smell or taste?* YES NO Have you, or a person with whom you live, been asked to self-isolate while waiting for COVID-19 test results?* YES NO If YES, when does your quarantine period end?* Have you, or a household member, tested positive to COVID-19 in the last 15days?* YES NO The QLD Government mask mandate applies to this business. Do you agree to wear a mask when in the reception areas and the waiting room?*YESNOName* First Last Date of your scheduled dental appointment?* DD slash MM slash YYYY Date* DD slash MM slash YYYY Signed*
