Patient Screening Questionnaire for COVID-19 

When the day of my appointment arrives, I confirm I will not attend the appointment if I have been in contact with anyone who has tested positive for COVID-19 in the past 10 days. 

I also confirm that I have had not experienced any of the following symptoms within the last 14 days – 

  • Continuous dry cough 
  • High temperature 
  • Loss of smell or taste