Covid Screening Form

PATIENT INFO

Covid Screening Form

Name *

Surname *

Contact number *

Your email address *

Have you ever tested positive for Covid – 19? If yes, please indicate date of positive Covid – 19 results:

Yes No

Have you received the Covid-19 vaccine?

Yes No

Are you allergic to Iodine / Shellfish?

Yes No

Are you allergic to Latex?

Yes No

Do you have any Thyroid condition?

Do you have any of the following symptoms? (PLEASE READ AND INDICATE CAREFULY)

Yes No

New, dry and / or persistent cough

Yes No

Shortness of breath / Difficulty breathing

Yes No

Fever

Yes No

Fatigue (feeling tired)

Yes No

Headache

Yes No

Muscle pains

Yes No

ANY other flu – like symptoms

Yes No

Loss of taste and / or smell

Yes No

G.I upset or diarrhoea

Yes No

Have you been in contact with anyone in the last 10 days who have or is currently experiencing these symptoms?

Yes No

Have you been in contact with anyone who has tested positive in the last 20 days?

Have you travelled nationally / internationally in the last month? If yes, where did you go?

Signed at Bellville: Date *

By ticking this box I accept the privacy policy and give Dr Hayes and her staff permission to process this information to contact me regarding the Handle me with care form information - POPIA

Enter Code*:

Physical Address

Unit 12
20 Bella Rosa Street
Rosenpark
Bellville, 7530

Contact Us

Tel: 021 910 1457

Email info@hayesdental.co.za

Enquire Click here

Map Directions

Social Media

Website Designed & Hosted by AltonSA.