COVID-19 IN-OFFICE SCREENING FORM Patient Name* First Last Date of Birth:* MM slash DD slash YYYY 1. Do you have a fever (above 38C) or have felt hot or feverish recently (14-21 days)?* Yes No 2. Are you having shortness of breath or other difficulties breathing?* Yes No 3. Do you have a cough?* Yes No 4. Do you have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?* Yes No 5. Have you experienced recent loss of taste or smell?* Yes No 6. Have you have a confirmed case of COVID-19 or have you had close contact with a confirmed case of COVID-19?* Yes No 7. Have you traveled in the last 14 days to any regions affected by COVID-19?* Yes No 8. Are you over the age of 60?* Yes No 9. Do you have any of the following: Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?* Yes No * I verify that the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have my dental treatment completed during the COVID-19 pandemic. EmailThis field is for validation purposes and should be left unchanged.
