Covid-19 Level 2 Questionnaire - City Dentists Wellington

Do you have a confirmed diagnosis of COVID-19? *

Yes
No

Are you waiting for a COVID-19 test or the results? *

Yes
No

Have you, or anyone living with you been quarantined or returned from overseas in the last 14 days? *

Yes
No

Have you had contact with someone with a confirmed diagnosis of COVID-19, or been in isolation with a suspected case in the last 14 days? *

Yes
No

Do you have any of the following symptoms: Cough, Sore throat, Shortness of breath, Runny nose, Sneezing, Post-nasal drip, Loss of smell? (with or without fever) *

Yes
No

Are you 70 years and over, or considered at increased risk (*) for developing severe COVID-19 infection because of a pre-existing health condition? *

Yes
No

* Patients considered at increased risk for severe COVID-19 include those with serious respiratory disease, serious heart conditions, immunocompromised conditions, severe obesity, diabetes, chronic kidney disease or those undergoing dialysis, liver disease and pregnant patients

I am *

a New Patient
an Existing Patient

Name *

First

Last

Mobile Phone Number *