HappyDental Triage Form for Patient and Staff Safety

Name *

First

Last

Appointment Date *

I confirm I am not presenting any of the following symptoms of COVID-19: *

Fever
Shortness of Breath
Dry Cough
Running Nose

I confirm that I have not travelled internationally or domestically using commercial transport such as: *

Bus
Train
Airline

I have not been exposed to any person or persons with COVID-19 to the best of my knowledge. *

I Agree

I am aware of the Social Distancing Protocols. *

I am aware

On the Arrival at the clinic your temperature will be checked, if it should be 38 Degree's or above we will have to refer you to your GP for further checks. We will NOT be able to treat you on this visit to the clinic *

I Understand

Signature

You have to sign this form once you checked in to Clinic.

NOTE: Please be aware when travelling to and from the clinic to make sure you take all the recommended Government Guidelines for travel in the current climate. If you should feel unwell please call us on 10 558 2015 and reschedule your appointment.

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