First Name (required)
Contact Email (required)
Do you have a confirmed diagnosis of COVID-19? (required)
Are you waiting for a COVID-19 test or the results? (required)
Have you, or anyone living with you, travelled internationally in the last 14 days? (required)
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)
Do you, or anyone living with you, have the following symptoms – with or without fever?
Sore Throat? (required)
Shortness of breath? (required)
Runny nose, sneezing, post-nasal drip (coryza)? (required)
Loss of smell (anosmia)? (required)
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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