COVID Patient Screening
Please complete the following survey 24 hours prior to your next dental appointment.
Patient First and Last Name *
Patient Email Address *
Today's Date
Do you have a fever or have you felt hot or feverish recently (14-21 days)? *
Are you having shortness of breath or other difficulties breathing? *
Do you have a cough? Or any other flu like symptoms, such as gastrointestinal upset, headache or fatigue? *
Have you experienced a loss of taste or smell? *
Have you taken Tylenol, Aspirin, Motrin, Advil or Aleve in the past 48 hours? *
Have you been in contact with any confirmed COVID-19 positive patients? *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy