Emergency Appointment

Appointment Date

Appointment Time

Your Name

Your Age

Address

Identification number of the National Register (see back of identity card) *

Phone No.

Your Email

Questionnaire

Corona triage questionnaire *

1. Do you have one or more of the following symptoms that fit with corona now or in the past 24 hours: - cold complaints (such as nose cold, runny nose, sneezing, sore throat) - cough - increase in fever (more than 38 ° C) - shortness of breath or tightness - loss of smell and/or taste

YesNo

2. Do you currently have a roommate with a fever or shortness of breath?

YesNo

3. Do you have corona now or have you been cured of corona less than 2 weeks ago?

YesNo

4. Do you now have roommates / family members with corona and have you been in contact with him / her in the past 2 weeks while he / she still had complaints?

YesNo

5. Are you in home isolation (mandatory quarantine) (due to direct contact with someone who has been diagnosed with the corona virus)?

YesNo

Dental Complaints:

1. intense pain

YesNo

2. Pain on pressure on the tooth

YesNo

3. Pain when cold

YesNo

4. Pain with heat

YesNo

5. Tooth broken

YesNo

6. Inflammation / abscess

YesNo

7. Filling or crown loosened

YesNo

8. Suffering after a recent treatment

YesNo

9. My tooth is loose

YesNo

10. My face/jaw is clearly swollen

YesNo

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Emergency Appointment

Appointment Date

Appointment Time

Your Name

Your Age

Address

Identification number of the National Register (see back of identity card) *

Phone No.

Your Email

Questionnaire

Corona triage questionnaire *

YesNo

2. Do you currently have a roommate with a fever or shortness of breath?

YesNo

3. Do you have corona now or have you been cured of corona less than 2 weeks ago?

YesNo

4. Do you now have roommates / family members with corona and have you been in contact with him / her in the past 2 weeks while he / she still had complaints?

YesNo

5. Are you in home isolation (mandatory quarantine) (due to direct contact with someone who has been diagnosed with the corona virus)?

YesNo

Dental Complaints:

1. intense pain

YesNo

2. Pain on pressure on the tooth

YesNo

3. Pain when cold

YesNo

4. Pain with heat

YesNo

5. Tooth broken

YesNo

6. Inflammation / abscess

YesNo

7. Filling or crown loosened

YesNo

8. Suffering after a recent treatment

YesNo

9. My tooth is loose

YesNo

10. My face/jaw is clearly swollen

YesNo

[anr_nocaptcha g-recaptcha-response]

Euro Dent Humbeek

Dorpsstraat 14, 1851 Humbeek,
Belgium

(0) 2-2697285

Euro Dent Mortsel

Prins Leopoldlei 8 – 10,
2640 Mortsel, Antwerp

(0) 3-4498374

Send us an e-mail

info@euro-dent.be

(0) 3-4498374

Euro Dent Mortsel:

Euro Dent Humbeek:

Emergency Dental Appointment

Emergency Appointment

Emergency Appointment

Euro Dent Humbeek

Euro Dent Mortsel

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