COVID-19 Patient Screening Form Name* First Last Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?* Yes (Pre-Appointment) No (Pre-Appointment) Yes (In-Office) No (In-Office) Are you/they having shortness of breath or other difficulties breathing?* Yes (Pre-Appointment) No (Pre-Appointment) Yes (In-Office) No (In-Office) Do you/they have a cough?* Yes (Pre-Appointment) No (Pre-Appointment) Yes (In-Office) No (In-Office) Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?* Yes (Pre-Appointment) No (Pre-Appointment) Yes (In-Office) No (In-Office) Have you/they experienced recent loss of taste or smell?* Yes (Pre-Appointment) No (Pre-Appointment) Yes (In-Office) No (In-Office) Are you/they in contact with any confirmed COVID-19 positive patients?* Yes (Pre-Appointment) No (Pre-Appointment) Yes (In-Office) No (In-Office) Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.Is your/their age over 60?* Yes (Pre-Appointment) No (Pre-Appointment) Yes (In-Office) No (In-Office) Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?* Yes (Pre-Appointment) No (Pre-Appointment) Yes (In-Office) No (In-Office) Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)* Yes (Pre-Appointment) No (Pre-Appointment) Yes (In-Office) No (In-Office) Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment. For testing, see the list of State and Territorial Health Department Websites for your specific area’s information.CAPTCHA