Crown Hill Smiles COVID Pre-Screening

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We are committed to the safety of our patients and our team members. We have implemented a robust safety plan, which includes screening of all individuals entering our office. We appreciate you taking the time to complete our COVID screening in advance of your visit to our office. Please note that we cannot confirm your appointment until this questionnaire has been submitted.

For more information on our safety plan, we invite you to visit our website at www.CrownHillSmiles.com

Email *

Patient's full name *

Do you have a fever, or have you felt hot or feverish lately (14-21 days)? *

Yes

Are you having shortness of breath or other difficulties breathing? *

Yes

Do you have a cough? *

Yes

Do you have any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue? *

Yes

Have you experienced recent loss of taste or smell? *

Yes

Have you been in contact with any confirmed or suspected COVID-19 patients in the last 14 days? *

Yes

If there is a change to any of the above responses before your scheduled visit, please notify us immediately by calling 206-781-1988. Please enter your INITIALS below. *

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