Pre-Appointment COVID-19 Patient Screening
C-Dental has always provided safe, clean and OSHA Compliant imaging centers. With these new COVID19 developments we have enhanced our protocols to be compliant with the new guidelines. Please take the time to fill out this screening questionnaire before attending your appointment at our imaging centers. Your answers will determine if we can confirm your appointment or if it will need to be rescheduled.
Patients who have received the COVID19 still have to be screened and follow safety guidelines.
Which imaging center is your appointment scheduled at?
San Francisco - West Portal
MDI - San Diego
MDI - La Mesa
MDI - Escondido
MDI - Encinitas
Date of Appointment
Have you recently been tested for COVID19? If so, are you waiting for your results?
If you are WAITING for your results, your appointment will have to be scheduled after you receive your results.
Yes and my results are negative.
Yes and I'm WAITING for my results.
No, I have not recently been tested.
Do you have fever or have you felt hot or feverish recently (past 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 traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location).
If you answer YES to this question, we cannot proceed with your appointment at this time and we will notify your referring dentist. The dentist may or may not advise you to see your primary care physician.
Are you in contact with any confirmed COVID-19 positive patients?
If you answer YES to this question, we cannot proceed with your appointment at this time and we will notify your referring dentist. The dentist may or may not advise you to see your primary care physician. IF YOU THINK YOU MIGHT HAVE BEEN EXPOSED AND HAVE NOT BEEN TESTED YOU WILL HAVE TO WAIT 14 DAYS BEFORE COMING IN.
Are you over the age of 60? Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
If you answer YES to this question, please reconsider scheduling your appointment when shelter-in-place orders are lifted. If you would like to proceed with your appointment, you will do so at your own risk.
Yes - over 60, but no underlying conditions
Yes - over 60 with underlying conditions
If you have taken a COVID19 test within the past 14 days, please provide your results. Use this link:
Have you received the COVID19 vaccine?
Patients who have received the vaccine still have to adhere to safety protocols.
Yes - but only one dose
Send me a copy of my responses.
Never submit passwords through Google Forms.
This form was created inside of C-Dental X-Ray.