COVID-19 Screening Questionnaire

This questionnaire has been implemented as a precautionary measure to help us keep you and our team safe. Screening questions must be answer prior to initiating any dental treatment.

Name*
First Last
Email*
Phone
Have you had a fever (99.5+) within the last 48 hours?*
- Yes
- No
Do you, a family member or someone of whom you have close contact with, have, or had the signs of acute respiratory illness such as coughing and shortness of breath within the last 21 days?*
- Yes
- No
Have you, a family member or someone with whom you've had close contact with experienced muscle aches, stomach pain or a sore throat within the last 21 days?*
- Yes
- No
Have you had close contact with anyone who has been diagnosed with COVID-19 within the last 21 days?*
- Yes
- No
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