Covid Screening - Norwest Paediatric Dentistry

Thank you for completing this form prior to entry.

Child's Surname:*

Child's/Children's First Name(s):*

Do you or any family member have a confirmed case of COVID-19?*

Yes
No

In the past 14 days, have you (or any family member) visited any NSW hotspots listed on the NSW Covid website? https://www.nsw.gov.au/covid-19/latest-news-and-updates*

Yes
No

Please give location and details

In the past 14 days, have you (or any family member) had any contact with someone with a confirmed or suspected case of COVID-19?*

Yes
No

Is your child or any household family member currently experiencing any of the following symptoms?

- Fever (38 degrees or higher):*

Yes
No

- Breathing difficulties/shortness of breath:*

Yes
No

- Cough:*

Yes
No

- Sore throat:*

Yes
No

- Fatigue or tiredness:*

Yes
No

- Any other Cold/flu symptoms such as runny nose or scratchy throat? Please note that even the mildest symptoms in the following LGAs require Covid testing: Fairfield, Liverpool, Cumberland, Parramatta, Bankstown (suburb), & Mt Druitt (suburb)*

Yes
No