Covid-19 Symptom Screening
*If you’ve tested positive for covid-19, please alert the office before your appointment*

    Patient Name:


    Do you have a fever or have you felt hot or feverish recently
    (in the past 14-21 days)?

    Have you been diagnosed with COVID-19?

    If yes, have you been retested?

    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?

    Are you in contact with any confirmed COVID-19 positive patients?

    Positive responses to any of these would likely indicate a deeper discussion with the dentist before
    proceeding with elective dental treatment.

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