COVID 19 Triaging Form

Triaging for COVID 19 is STILL required in Level 1 under Dental Council guidelines. Please fill out this form, if you have an appointment in the next 24 hours ONLY. This form is not valid if it is filled more than 24 hours in advance. We have been asked to maintain practical distancing in our waiting areas. Only ONE attender will be allowed with a disabled or elderly patient or a child, into the practice. Thank you for your kind understanding.

First name

Last name

Are you a registered patient with MDental?
Yes No

If you are not a patient who is registered with us, please go to the Registration Forms link on our website and register with us by filling out a two page Registration and Medical history form. This can be done AFTER you fill out this form. We will not be able to see you or give you a prescription until you have completed our registration process.

Name of your dentist if you are not a registered patient with MDental ? By filling this section, you consent to our seeking your dental records from your dentist.

Date of birth(dd/mm/yyyy):

Do you have a confirmed diagnosis of COVID 19?
Yes No

Are you waiting for a COVID 19 test or the results?
Yes No

Have you traveled overseas in the last 14 days, or had contact with someone who has returned from overseas in the last 14 days?
Yes No

Have you had close contact with other people in the last 14 days who are probable or confirmed to have COVID-19?
Yes No

Do you have any of the following symptoms?
Cough
Sore throat
Fever
Shortness of breath
Loss of taste
Loss of smell
Runny nose, sneezing, post nasal drip (Coryza)
I only have the above symptoms
I have none of the above symptoms

I have answered all questions above to the best of my ability and I certify that the information provided is true
Yes No

Do you work or have you recently worked at an international airport / maritime port in areas visited by international arrivals?
Yes No

Are you household member or community contact of air crew?
Yes No

Do you work / have you recently worked in customs / immigration or at managed quarentine / isolation facility?
Yes No

I provide general consent to the dentists at MDental to provide me with dental advice, treatment or a prescription.

Form filled and submitted by:
Parent
Guardian
Patient

Patient/Parent/Guardian's name

After you have clicked the 'Submit' button on the left, you should receive a confirmation message that your form(s) has/have been submitted. If you do not receive a confirmation message, please contact the practice on 020 433 6825 (020 4 DENTAL) or email the practice at info@mdental.co.nz . We unfortunately cannot see you for your appointment until your triaging form has been completed.