We look forward to connecting

Patient Name:


PRE-APPOINTMENT DATE:
IN-OFFICE DATE:
Do you/they have fever or have you/they felt hot or feverish
recently
YesNo
YesNo
Are you/they having shortness of breath or other difficulties
breathing?
YesNo
YesNo
Do you/they have a cough?
YesNo
YesNo
Any other flu-like symptoms, such as gastrointestinal upset,
headache or fatigue?
YesNo
YesNo
Have you/they experienced recent loss of taste or smell?
YesNo
YesNo
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.
YesNo
YesNo
Is your/their age over 60?
YesNo
YesNo
Do you/they have heart disease, lung disease, kidney disease,

diabetes or any auto-immune disorders?
YesNo
YesNo
Have you/they traveled in the past 14 days to any regions affected
by COVID-19? (as relevant to your location)
YesNo
YesNo
Positive responses to any of these would
likely indicate a deeper discussion with the dentist before proceeding with
elective dental treatment.

Should you develop any of the above signs or symptoms within 14 days of your appointment with our office, please call and let us know.



 For testing, see the list of href="https://www.cdc.gov/publichealthgateway/healthdirectories/healthdepartments.html">State
and Territorial Health Department Websites for your specific area’s
information.