Solihull Orthodontic Centre Pre-appointment Covid-19 Questionnaire

This form MUST be completed for EVERY appointment and submitted by 8.30am on the day of your appointment.

First Name (required) Last Name (required) Email (required)
Please answer ALL questions below.
Q1. Do you live with someone who is currently self isolating?

Pre-Appointment YesNo
Day of Appointment YesNo


Q3. Are you having shortness of breath or other difficulties breathing?

Pre-Appointment YesNo
Day of Appointment YesNo


Q5. Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Pre-Appointment YesNo
Day of Appointment YesNo


Q7. Are you in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Pre-Appointment YesNo
Day of Appointment YesNo


Q9. Do you have heart disease, lung disease, kidney disease, diabetes or any autoimmune disorders?

Pre-Appointment YesNo
Day of Appointment YesNo


Q11. Have you been part of any mass gatherings or had close contact with many unacquainted people?

Pre-Appointment YesNo
Day of Appointment YesNo


If you have a positive response to any of these questions please call the Practice on 0121 711 2727 well in advance of your scheduled appointment.



Please check the box below before sending.