COVID-19 Patient Screening Form Jun 23, 2020 Thank you for completing the COVID-19 Patient Screening form! 1 0% https://carydentalcenter.com/wp-content/plugins/nex-formsfalsemessagehttps://carydentalcenter.com/wp-admin/admin-ajax.phphttps://carydentalcenter.com/patient-screening-formyes1 *Patient Name*Patient Email*Patient Cell Phone Number*DateTime*Do you/they have fever or have you/they felt hot or feverish recently (14/21 days)?YesNo*Are you/they having shortness of breath or other difficulties breathing?YesNo*Do you/they have a cough?YesNo*Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?YesNo*Have you/they experienced recent loss of taste or smell?YesNo*Are you/they in contact with any confirmed COVID-19 positive patients?Patients who are well but have a sick family member at home with COVID-19 should consider postponing elective treatment.YesNo*Is your age over 60?YesNo*Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?YesNo*Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)YesNoPositive responses to any of these would likely indicates a deeper discussion with the dentist before proceeding with elective dental treatment.Submit
