Confidential Patient Questionnaire
Garden City Dental
Do you have a confirmed diagnosis of COVID-19? *
Are you waiting for a COVID-19 test or the results, or considered a probable case, or been asked to self-isolate? *
Have you had close contact with other people in the last 14 days who are probable or confirmed to have COVID-19? *
Do you have new or worsening symptoms of an acute respiratory infection with at least one of the following: (with or without fever)
Have you travelled overseas in the last 14 days? *
Have you had direct contact with someone in the last 14 days who has travelled overseas? *
Do you work on an international aircraft or shipping vessel? *
Do you work or have you recently at an international airport or maritime port in areas/conveniences visited by international arrivals? *
Do you work or have you recently worked in customs, immigration, or at managed quarantine/isolation facilities? *
Are you a household member or a community contact of aircrew? *
Are you or anyone in your household or anyone coming with you to your appointment feeling unwell? *
First Names *
Surname *
Date of Birth *
Cell Phone number
Other Phone
Email *
Address *
Parent or Guardian name if under 16
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
Please list any current medications
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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