Crown Hill Smiles COVID Pre-Screening
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)? *
Are you having shortness of breath or other difficulties breathing? *
Do you have a cough? *
Do you have any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue? *
Have you experienced recent loss of taste or smell? *
Have you been in contact with any confirmed COVID-19 patients in the last 14 days? *
If there is a change to any of the above responses between now and your scheduled visit, you agree to notify us by phone before your appointment. Please INITIAL in acknowledgement of this policy. *
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