Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Are you/they having shortness of breath or other difficulties breathing?
Do you/they have a cough?
Are you/they experiencing chills or repeated shaking with chills?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you/they experienced recent loss of taste or smell?
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. )
Have you been tested for COVID-19 in the last 14 days?
If “no,” proceed to the next question.
If yes, what is the result of the testing?
If still waiting on results, schedule an appointment after results are known.
I agree to notify the dental practice if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19.