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Patient Screening Form

Patient Information

First Name: *

Last Name: *

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? *

Yes No  

Are you/they having shortness of breath or other difficulties breathing? *

Yes No  

Do you/they have a cough? *

Yes No  

Any other flu-like symptoms, such as gastronintestinal upset, headache or fatigue? *

Yes No  

Have you/they experienced recent loss of taste or smell? *

Yes No  

Are you/they in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. *

Yes No  

Is your/their age over 60? *

Yes No  

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? *

Yes No  

Have you/they traveled in the past 14 days to any regions affected by COVID-19 (as relevant to your location)? *

Yes No  

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing, see the list of State and Territorial Health Department Websites for your specific area's information.

 

Confirmation

 
 

Please wait, it may take a moment to submit your information.

 

Respected As A Patient



I continue to be impressed with every aspect of dental care and service at your office. Everyone is wonderful and makes me feel important, valued, and respected as a patient; everything is explained in detail.
-Shelley D.
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