Screening Questions for COVID-19 for use in

Solihull Orthodontic Centre from June 9th 2022

    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.
    1. Do you have any of the following symptoms:

    • high temperature or fever?
    • new, continuous cough?
    • a loss or alteration to taste or smell?
    • sickness or diarrhoea

    YesNo

    2. Do you or any member of your household/family currently have COVID-19?

    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.