Confidential Patient Questionnaire
Garden City Dental
Have you tested positive to COVID-19 *
Have you been in contact with a person with confirmed or suspicion of exposure to COVID-19 in the last 14 days? *
Your answer
Have you , or anyone coming with you to your appointment or anyone in your household travelled internationally or domestically within the last 14 days? *
Your answer
Are you or anyone in your household or anyone coming with you to your appointment feeling unwell? *
Your answer
First Names *
Your answer
Surname *
Your answer
Date of Birth *
Your answer
Cell Phone number
Your answer
Other Phone
Your answer
Email *
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 *
Have you had any of the following:
Do You Smoke *
Do you Vape *
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. 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. *
Required
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