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Questionnaire for New Patients
Questionnaire for New Patients
Full Name
*
Date of Birth
*
DD
MM
YYYY
Covid 19 questionnaire
1. Have you been Tested for Covid 19?
*
Yes
No
2. Have you travelled overseas and/or interstate in the last 14 days?
*
Yes
No
3. Have you come in contact with a person who has tested Covid 19 positive?
*
Yes
No
4. Are you currently experiencing Fever, Shortness of breath, Chest pain and/or coughing?
*
Yes
No
Further Questions
1. Are you on Steroids?
*
Yes
No
2. Are you suffering from Autoimmune Disease?
*
Yes
No
3. Do you have uncontrolled Diabetes?
*
Yes
No
4. Undergoing Cancer Treatment / Chemo Therapy?
*
Yes
No
5. Do you have a Weakened Immune System - Susceptible to getting the flu?
*
Yes
No
6. Are you taking Immunosuppressive Drugs?
*
Yes
No
7. Have you undergone any Transplant Procedures/Surgery?
*
Yes
No
8. Do you have Athsma, Emphysema or Chronic Bronchitis?
*
Yes
No
9. Are you suffering from Lung Disease or Lung Related issues?
*
Yes
No
10. Are you suffering from Heart Disease - Vascular Heart Disease or Valve Replacement?
*
Yes
No
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Home
About
Our Services
▼
Services Overview
General Dentistry
Dental Implants
DaVinci Smiles™ All Teeth Implants Package
All-on-4™ Dental Implants
Cosmetic Dentistry
Crowns and Bridgework
Teeth Whitening
Dentures
Invisalign
Porcelain Veneers
Sleep Dentistry
Wisdom Teeth Removal
Dental Emergencies
Payment Plans
▼
Dental Payment Plans
Afterpay
FAQ’s
Blog
Contact
▼
Contact Us
Dental Careers