Screening Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY PhoneEmail Have you had a fever or have felt hot or feverish in the past 14 days?*YesNoDo you have shortness of breath or difficulty breathing?*YesNoDo you have a cough?*YesNoDo you have any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?*YesNoHave you experienced recent loss of taste or smell?*YesNoHave you come in contact with any confirmed COVID-19 positive patients?*YesNoIs your age over 60?*YesNoDo you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?*YesNoHave you traveled in the past 14 days to any regions with widespread COVID-19?*YesNoAcknowledgement* Positive responses to any of these questions may result in a deeper discussion with the dentist before proceeding with elective dental treatment. Positive responses alone will not exclude you from your scheduled appointment.Responses* The responses above are true to the best of my knowledge