First Name (required)
Contact Email (required)
Do you have a confirmed diagnosis of COVID-19? (required) YesNo
Are you waiting for a COVID-19 test or the results? (required) YesNo
Have you, or anyone living with you, travelled internationally in the last 14 days? (required) YesNo
Have you, or anyone living with you, had contact with a confirmed diagnosis of COVID-19, or been in isolation with a suspected case of COVID-19 in the last 14 days? (required) YesNo
Do you, or anyone living with you, have the following symptoms – with or without fever?
Sore Throat? (required) YesNo Cough? (required) YesNo Shortness of breath? (required) YesNo Runny nose, sneezing, post-nasal drip (coryza)? (required) YesNo Loss of smell (anosmia)? (required) YesNo
Do you have any of the following health conditions? (if applicable) Heart DiseaseLung DiseaseKidney DiseaseDiabetesOther Autoimmune Disorder
If you have a health condition, please briefly detail here:
I understand that Shakespeare Orthodontics has set up their practice to reduce the risk of contracting COVID-19 according to the joint Ministry of Health and Dental Council “Guidelines for oral health services at COVID-19 Alert Level 2.” I have opted to attend my orthodontic treatment appointment on my own accord, and am aware of the risks of contracting COVID-19 in such a public place despite these best practice precautions. (required)
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