Confidential Patient Questionnaire
Garden City Dental
* Required
Do you have a confirmed diagnosis of COVID-19?
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Yes
No
Are you waiting for a COVID-19 test or the results, or considered a probable case, or been asked to self-isolate?
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Your answer
Have you had close contact with other people in the last 14 days who are probable or confirmed to have COVID-19?
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Your answer
Do you have new or worsening symptoms of an acute respiratory infection with at least one of the following: (with or without fever)
cough
sore throat
shortness of breath
runny nose, sneezing, post-nasal drip
loss of smell
Have you travelled overseas in the last 14 days?
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Your answer
Have you had direct contact with someone in the last 14 days who has travelled overseas?
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Your answer
Do you work on an international aircraft or shipping vessel?
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Your answer
Do you work or have you recently at an international airport or maritime port in areas/conveniences visited by international arrivals?
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Your answer
Do you work or have you recently worked in customs, immigration, or at managed quarantine/isolation facilities?
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Your answer
Are you a household member or a community contact of aircrew?
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Your answer
Are you or anyone in your household or anyone coming with you to your appointment feeling unwell?
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Your answer
First Names
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Your answer
Surname
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Your answer
Date of Birth
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Your answer
Cell Phone number
Your answer
Other Phone
Your answer
Email
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Your answer
Address
*
Your answer
GP
Your answer
Parent or Guardian name if under 16
Your answer
Have you been admitted to hospital in the last 2 years
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Yes
No
Have you had any of the following:
Rheumatic Fever
Asthma
Infective Endo Carditis
Chest/ Breathing problems
High Blood Pressure
Low Blood Pressure
Bronchitis
Thyroid Problems
Heart Murmur
Arthritis
Heart Valve Replacement/Defect
Osteoporosis
Bleeding Problems
Stroke
Epilepsy
Angina
Anaemia
Diabetes
Fainting Attacks
Kidney Trouble
Gastric Problems
Cancer
HIV/AIDS
Artificial/ Prosthetic Joint
Been treated with Corticosteroids
Currently Pregnant
Hepatitis A
Hepatitis B
Hepatitis C
Do You Smoke
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Yes
No
Do you Vape
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Yes
No
Please list any allergies or bad reactions to drugs or substances
Your answer
Please list any current medications
Your answer
Payment is expected on the day of treatment, please note we no longer accept cash or cheque payments. Our debt collection fees will be added to any unpaid fee on the day. Where clients are in breach of agreed payment terms, we may disclose this information to debt collection agencies and legal proceedings may follow. This may result in your name and address being entered into the Computer Bureau default listing which may have an impact on your credit rating. The minimum fee for an appointment will be $80. Security cameras operate on these premises.
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