COVID-19 Screening
Please fill out this screening form on the morning of your scheduled dental visit.
You'll answer a few questions about symptoms and contact you've had with others to help us determine whether or not to proceed with your dental care today.
Thank you for your understanding.
First Name *
Last Name *
Have you been diagnosed with COVID-19 in the past 14 days? *
Have you been diagnosed as a "person under investigation" for COVID-19 now or in the past 14 days? *
Have you had close contact with someone diagnosed with COVID-19 in the past 14 days? *
Please select which of the following symptoms you currently have or have had within the past 14 days: *
Required
Have you taken any fever reducing or cough suppressant medications in the past 72 hours? *
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