Online Booking - Covid-19 Questionnaire | City Dentists Wellington

Are you fully vaccinated for Covid-19? (2 doses) *

Yes
No

You have a valid Covid-19 Vaccine Pass

Do you or any member of your household have COVID-19 or are you waiting for a COVID-19 PCR or RAT test result? *

Yes
No

Are you required to self-isolate (including arrival from overseas)? *

Yes
No

Do you have ANY of the following symptoms now, or in the last 14 days? Fever, Acute Cough, Shortness of breath, Muscle aches, Loss of smell, Sore throat or Generally feeling unwell with no other likely diagnosis *

Yes
No

Do you have any other reason to think that you are at risk of having COVID-19? *

Yes
No

If you've had Covid; Are you symptom free and with a negative RAT test? *

Yes
No

I am *

a New Patient
an Existing Patient

Name *

First

Last

Mobile Phone Number *

Online Booking – Covid-19 Questionnaire