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Covid 19 Questionnaire

Please read carefully before continuing.

When entering our practice your hands will be sanitized and your temperature recorded. Should your temperature be above 37.3, we will ask to reschedule your appointment.

Each staff member in the surgery (dentist and assistant or the hygienist) will be dressed in the appropriate attire such as shoe covers, head cover, apron or gown, KN95 mask and face shield.

You will be given a mouth rinse to rinse with for 30 seconds before a procedure, this eliminates the viral load, should it be present.

All surfaces in the room are disinfected after each patient.

Gowns are worn when procedures concerning aerosol are carried out. When you settle your account, the card and card machine get wiped down before and after use with a disinfectant wipe.

You also have the option to sanitize your hands before leaving the practice.

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Date Filling in this Form
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Your First Name
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Your Last Name
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Date of Birth
YYYY/MM/DD
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Biological Sex:
Please note, this field does not refer to your Gender Identity.
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Street Address:
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Optional
Street Address Line 2
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City
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  • - select a province -
  • Western Cape
  • Eastern Cape
  • Northern Cape
  • North West
  • Free State
  • Kwazulu Natal
  • Gauteng
  • Limpopo
  • Mpumlanga
- select a province -
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Area Code (ZIP)
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Your E-mail Address
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Your Phone Number
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Optional
Alternative Phone Number
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These questions must be answered honestly under penalty of law. An answer of YES does not exclude you from treatment.

Please answer YES or NO to each of the following questions:
Do you have a fever or above normal temperature?
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Please give a reason for answering "yes".
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Have you experienced shortness of breathe or had trouble breathing?
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Please give a reason for answering "yes".
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Do you have a dry cough?
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Please give a reason for answering "yes".
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Do you have a runny nose?
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Please give a reason for answering "yes".
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Have you recently lost or had a reduction in your sense of smell?
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Please give a reason for answering "yes".
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Do you have a sore throat?
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Please give a reason for answering "yes".
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Have you been in contact with someone who has tested positive for COVID-19?
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Please give a reason for answering "yes".
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These questions must be answered honestly under penalty of law. An answer of YES does not exclude you from treatment.

Please answer YES or NO to each of the following questions:
Have you tested for COVID-19?
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Please give a reason for answering "yes".
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Have you been tested for COVID-19 and are awaiting results?
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Please give a reason for answering "yes".
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Do you have a weakened immune system?
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Please give a reason for answering "yes".
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Are you currently undergoing treatment for cancer, such as chemotherapy or radiation therapy?
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Please give a reason for answering "yes".
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Do you have an autoimmune disease such as Lupus, rheumatoid arthritis, multiple sclerosis, or psoriasis?
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Please give a reason for answering "yes".
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Do you have diabetes?
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Please give a reason for answering "yes".
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If so, do you have to take insulin injections?
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Please give a reason for answering "yes".
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Do you have asthma or COPD?
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Please give a reason for answering "yes".
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Dependent / Child First Name
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Dependent / Child Last Name
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Optional Comments regarding your child or dependent.
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Any additional comments...
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Dental procedures take place with the patient in very close proximity to the service provider. This potentially exposes the patient and the operator to saliva and to coolant water spray, which may spread the disease. The ultra-fine nature of the spray and droplets may linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.
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Kindly tick the "TAP ME TO CONFIRM" box to acknowledge that the answers you provided are true and accurate to the best of your knowledge.
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Click here to read our Privacy and Personal Data Policy
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