COVID-19 SCREENING QUESTIONS

Please read the following information and fill out the form below before your appointment at Totara House Clinic

At Totara House Clinic we continue to do our best to keep our patients and staff safe while providing uninterrupted service for as many of our patients as possible. We must balance this with the risk that ENT specialists might be exposed to when in contact with their patients. After all, most of our examination techniques necessitate close interaction with our patients.

We are taking our lead from the Ministry of Health. You will find useful information on their website www.health.govt.nz and on www.covid19.govt.nz.

Under the COVID-19 Protection Framework (traffic light system) everyone coming to our clinic are required to:

Wear a MEDICAL GRADE MASK. We will provide one for you if you don't have one. (This includes children over the age of 12). We also have masks for children if you would like one.
SANITISE your hands with our alcohol based hand sanitiser on entry and exit to our clinic.

You can also help keep us safe by completing the checklist below prior to your next visit to our practice.

Patient's Name

Patient's Date of Birth:

Are you the patient or support person?

Name of Support Person:

Phone

Do you have any of the following symptoms?

New or worsening cough?

Sneezing and a runny nose?

Fever?

A temporary loss of smell or altered sense of taste?

Sore throat?

Shortness of breath?

Have you or someone in your house tested positive for COVID-19 in the last 7 days?

Address

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