COVID-19 Screening Form 2022
Dental on Raffles - 106 Raffles Street, Napier South, Napier 4110
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
*
-
Day
-
Month
Year
Date
What is your vaccine status?
*
Unvaccinated
Had one vaccine
Had both vaccines – no COVID-19 vaccine passport
Had both vaccines – has COVID-19 vaccine passport
Do you have COVID-19 or are waiting for test results?
*
Yes
No
Are you currently self isolating?
*
Yes
No
Have you been to any locations of interest in any region?
*
Yes
No
Are you suffering from any of the following symptoms?
*
Fever, cough, shortness of breath
Muscle aches, loss of smell, sore throat
Generally feeling unwell with no other likely diagnosis
None of these symptoms
Submit
Should be Empty: