COVID-19 SCREENING QUESTIONNAIRE PLEASE FILL THE QUESTIONS BELOW AND SUBMIT THIS FORM BEFORE YOUR APPOINTMENT AT MOLONGLO DENTAL Your name Your email Have you been Vaccinated against Covid-19? Both DoseSingle DoseNoN/A Covid Screening Questions Have you travelled out of Canberra in last 3 week? NY Are you experiencing any of the following: Back Pain NY Cough NY Blocked nose NY Temperature / Fever NY Hard to Breathe NY Headaches NY Have you had a Covid-19 test done in the last seven days? NY Have you been a close/casual contact to a confirmed case? NY If you have answered Yes to any of the above Covid screening questions, please provide detail so we can reschedule your appointment to a later date. Appointment Date & Time
