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Patient corona virus questionnaire

Patient Corona Virus Questionnaire 2020

Patient's first name*

Patient's last name*

Patient Appointment Date*

Patient Appointment Time*

Email*

Phone*

1. Do you have or have had a fever in the last 2 weeks?

Yes

No

2. Do you have or have had a cough in the last 2 weeks?

Yes

No

3. Do you have or have had a sore throat in the last 2 weeks?

Yes

No

4. Do you have or have had shortness of breath in the last 2 weeks?

Yes

No

5. Have you been exposed to someone with any of the above in the last 2 weeks?

Yes

No

6. Have you travelled outside of Queensland in the last 2 weeks

Yes

No

Where have you travelled?*

7. Have you been exposed to a confirmed COVID-19 case or someone associated with them?

Yes

No

Are you attending this appointment alone? *

Yes

No

Accompany persons details:

I solemnly and sincerely swear that the below is true & accurate for:

Accompanying persons First Name *

Accompanying Persons Last name *

1. Do you have or have had a fever in the last 2 weeks?

Yes

No

2. Do you have or have had a cough in the last 2 weeks?

Yes

No

3. Do you have or have had a sore throat in the last 2 weeks?

Yes

No

4. Do you have or have had shortness of breath in the last 2 weeks?

Yes

No

5. Have you been exposed to someone with any of the above in the last 2 weeks?

Yes

No

6. Have you travelled outside of Queensland in the last 2 weeks

Yes

No

Where have you travelled?*

7. Have you been exposed to a confirmed COVID-19 case or someone associated with them?

Yes

No

*** Please remember only one person can attend with you, others will be asked to leave immediately ***

I have read and understood the above and I am aware it is a CRIMINAL offence to supply misleading information and Qld Health will be notified.

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By clicking submit you are agreeing to our privacy policy

Why we’re the clear choice for your treatment

Trust the team at SmileStyle Orthodontics to deliver the smile results you want.

1.

1,000 happy smiles created with Invisalign®

We are your local Diamond Invisalign® providers.

2.

Two convenient locations and easy parking

Come visit us in Loganholme or Capalaba.

3.

Excellent results for the whole family

It’s never too late to achieve your dream smile.

4.

State-of-the-art technology

We use the latest equipment to bring you the best results.

5.

30 years of specialist experience

We can treat even complex orthodontic issues at our practice.

6.

No deposit, no interest payment options

We keep a straight smile attainable on any budget.

Meet Dr Tselepis Meet our team

Loganholme
Capalaba

70 Bryants Road Loganholme Queensland 4129 Australia

enquire@michaeltselepis.com

Monday - Friday: 8am - 5pm
Wednesday: Closed
Saturday: Closed
Sunday: Closed

Suite 4 76 Old Cleveland Rd Capalaba Queensland 4157 Australia

enquire@michaeltselepis.com

Wednesday only:: 8am - 5pm

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