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

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

    YesNo

    2. Have you or any member of your household/family had a confirmed diagnosis of COVID-19 in the last 10 days?

    YesNo
    3. Are you or any member of your household/family waiting for a COVID-19/SARS-CoV-2 PCR test result?

    YesNo
    4. Have you travelled internationally in the last 10 days to a country that is on the Government red list?

    YesNo
    5. Have you or any member of your household/family been advised to isolate by any NHS organisation in the last 10 days?

    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.