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Cosmetic, Implant and General Dentistry
Date of Birth:
Do you have fever or have you felt hot or feverish in the last 21 days? YesNo
Are you having shortness of breath or other difficulties breathing? YesNo
Do you have a cough? YesNo
Do you have any other flu-like symptoms, such as stomach upset, headaches, body aches or fatigue? YesNo
Have you experienced a recent loss of smell or taste? YesNo
Are you in contact with anyone who shows any sign of flu? YesNo
Are you in contact with anyone who is COVID-19 positive? YesNo
Have you ever been tested positive for COVID-19 in the last 21 days? YesNo
Have you been travelling in the last 14 days? YesNo
I confirm to the best of my knowledge, that the above information is complete and correct. I agree that the information provided above can be used confidentially for medical and internal purposes by U Smile Dental Practice
I have read, understood and agree to the privacy notice
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