Screening

Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Phone
Email
Have you had a fever or have felt hot or feverish in the past 14 days?*
- Yes
- No
Do you have shortness of breath or difficulty breathing?*
- Yes
- No
Do you have a cough?*
- Yes
- No
Do you have any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?*
- Yes
- No
Have you experienced recent loss of taste or smell?*
- Yes
- No
Have you come in contact with any confirmed COVID-19 positive patients?*
- Yes
- No
Is your age over 60?*
- Yes
- No
Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?*
- Yes
- No
Have you traveled in the past 14 days to any regions with widespread COVID-19?*
- Yes
- No
Acknowledgement*
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