COVID-19 Screening Form 2020
Dentist @ Parkside 514 Kennedy Rd, Napier. Ph: 06 8453 544
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Of Birth
*
-
Month
-
Day
Year
Date
Are you a registered patient with Dentist @ Parkside?
*
Yes
No
Name of your GP or Medical Centre?
*
Are you suffering from any of the following symptoms?
*
Sore throat
Runny nose
Post nasal drip
Sneezing
Cough
Fever
Shortness of breath
Loss of taste
Loss of smell
None of the above symptoms
Have you returned from overseas travel in the last 14 days?
*
Yes
No
Have you been in contact with anybody who has returned from overseas travel in the last 14 days?
*
Yes
No
Have you been in contact with anybody who has been in self isolation or has been quarantined?
*
Yes
No
Have you been in contact with anybody who may be a suspect case for COVID 19 (Coronavirus Disease)?
*
Yes
No
Please describe your urgent dental problem. Please be accurate with information to enable us to help
*
SWELLING : Only fill this section if you have a swelling, otherwise go to the next section on Trauma
*
My swelling is visible on my face
I have a swelling in my mouth
I cannot eat/drink because of my swelling
I am having difficulty breathing
I am having difficulty swallowing
I am already taking antibiotics
TRAUMA : Only fill this section if you have suffered dental trauma, otherwise go to the next section
I have had an accident and have a broken tooth
I have had an accident and I am bleeding profusely. Please contact Hastings Hospital if the bleeding
Been in an incident and I might have a broken jaw. Please contact Hastings Hospital.
DENTAL PAIN : On a scale of 1-10 how would you rate your dental pain?
*
Describe your dental pain. e.g. Comes on by itself, sore only when eating, lasts for short time…
Have you taken medications for the pain? If yes, please list which drugs:
*
Do you have an allergy to ANY medication?
*
Yes
No
If yes, please list drugs below:
I have answered all questions above to the best of my ability and I certify that the information pro
*
Yes
No
Submit
Should be Empty: