Pre-appointment Patient Screening Form
Please answer these questions prior to arriving the office
  • / /
  • - -
  • / / :
  • Yes No
    Do you have fever or have you felt hot or feverish recently (14-21 days)?
    Are you having shortness of breath or other difficulties breathing?
    Do you have a cough?
    Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
    Have you experienced recent loss of taste or smell?
    Have you been in contact with any confirmed COVID-19 positive patients?
    Is your age over 60?
    Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
    In the past 14 days, have you traveled to any regions affected by COVID-19? (as relevant to your location)
  • Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

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