COVID-19 pre-screening questionnaire (please complete no more than 24 hours before your appointment) WITHIN THE LAST 14 DAYS, HAVE YOU EXPERIENCED A NEW COUGH THAT YOU CANNOT ATTRIBUTE TO ANOTHER HEALTH CONDITION?* YESNO WITHIN THE LAST 14 DAYS, HAVE YOU EXPERIENCED NEW SHORTNESS OF BREATH THAT YOU CANNOT ATTRIBUTE TO ANOTHER HEALTH CONDITION?* YESNO WITHIN THE LAST 14 DAYS, HAVE YOU EXPERIENCED A NEW SORE THROAT, LOSS OF TASTE OR SMELL THAT YOU CANNOT ATTRIBUTE TO ANOTHER HEALTH CONDITION?* YESNO WITHIN THE LAST 14 DAYS, HAVE YOU HAD A TEMPERATURE AT OR ABOVE 37.8°C OR THE SENSE OF HAVING A FEVER?* YESNO WITHIN THE LAST 14 DAYS, HAVE YOU HAD CLOSE CONTACT WITH SOMEONE WHO IS OR WAS SICK WITH SUSPECTED OR CONFIRMED COVID-19? (NOTE: CLOSE CONTACT IS DEFINED AS WITHIN 6 FEET FOR MORE THAN 10 CONSECUTIVE MINUTES)* YESNO WITHIN THE LAST 14 DAYS, HAVE YOU OR A HOUSEHOLD MEMBER BEEN ISOLATING?* YESNO If you answer yes to any of these questions, please reschedule your appointment TERMS AND CONDITIONS* I HAVE READ THE PRACTICE REOPENING PROCEDURES (ON THE PRETTYGATE DENTAL WEBSITE) WHICH OUTLINES THE MEASURES PRETTYGATE DENTAL HAVE TAKEN TO MINIMISE RISKS TO PATIENTS AND UNDERSTAND THERE ARE THEORETICAL RISKS IN ATTENDING MY OR MY CHILD’S APPOINTMENT AND AGREED TO ATTEND THE PRACTICE. PARENT /PATIENT SIGNATURE* Δ
