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COVID-19 Guidelines for Patient Appointments
Pre-appointment COVID-19 Screening
Step 1 of 6
16%
Name
*
First
Last
In the past 14 days, have you tested positive for COVID-19?
*
Yes
No
What date was the test?
Date Format: MM slash DD slash YYYY
Have you been symptom free for 24 hours?
*
Yes
No
In the past 14 days, have you been exposed to any confirmed COVID-19 patients?
*
Yes
No
Patients who are well, but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
In the past 14 days, have you traveled outside the local area?
*
Yes
No
Do you have a fever or have you felt hot or feverish recently (past 14-21 days)?
*
Yes
No
Are you having shortness of breath or other difficulties breathing?
*
Yes
No
Do you have a cough?
*
Yes
No
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
*
Yes
No
Have you experienced any recent loss of taste or smell?
*
Yes
No
Are you over the age of 60?
*
Yes
No
Do you have heart disease, lung disease, kidney disease, diabetes, autoimmune disorders, dementia, or are you/they pregnant?
*
Yes
No
Your Contact Information
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Date of Birth
*
Date Format: MM slash DD slash YYYY