Screening Form COVID-19
Queens Family Dentistry
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Full First and Last Name of who the appointment is for: *
Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating or staying at home? *
In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?  
If yes provide date
In the last 5 days have you experienced any of these symptoms? *
I agree, if I develop any of the symptoms listed or test positive for COVID-19, before my appointment I will notify Queens Family Dentistry.
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