Full Name * This field is required.

Phone * This field is required.

PRE-APPOINTMENT

Date

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

Yes or No

Yes
No
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List is empty.

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

Yes or No

Yes
No
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List is empty.

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3. Do you/they have a cough?

Yes or No

Yes
No
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List is empty.

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4. Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes or No

Yes
No
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List is empty.

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

Yes or No

Yes
No
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List is empty.

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6. 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 or No

Yes
No
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7. Is your/their age over 60?

Yes or No

Yes
No
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8. Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Yes or No

Yes
No
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List is empty.

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

Yes or No

Yes
No
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List is empty.

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IN-OFFICE

Date

This field is required.

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

Yes or No

Yes
No
No elements found. Consider changing the search query.
List is empty.

This field is required.

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

Yes or No

Yes
No
No elements found. Consider changing the search query.
List is empty.

This field is required.

3. Do you/they have a cough?

Yes or No

Yes
No
No elements found. Consider changing the search query.
List is empty.

This field is required.

4. Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes or No

Yes
No
No elements found. Consider changing the search query.
List is empty.

This field is required.

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

Yes or No

Yes
No
No elements found. Consider changing the search query.
List is empty.

This field is required.

Yes or No

Yes
No
No elements found. Consider changing the search query.
List is empty.

This field is required.

7. Is your/their age over 60?

Yes or No

Yes
No
No elements found. Consider changing the search query.
List is empty.

This field is required.

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

Yes or No

Yes
No
No elements found. Consider changing the search query.
List is empty.

This field is required.

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

Yes or No

Yes
No
No elements found. Consider changing the search query.
List is empty.

This field is required.

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.

PRE-APPOINTMENT

IN-OFFICE

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.

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