DR. DOLLAR PRE-APPOINTMENT COVID-19 PATIENT SCREENING FORM

Due to COVID-19, we have prepared this screening form for each patient to complete within 24 hours of each dental appointment. Thank you for assisting in keeping everyone safe!

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* 1. What is your first name?

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* 2. What is your LAST NAME INITIAL ONLY?

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* 3. What is your phone number?

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* 4. Are you in contact with any confirmed COVID-19 positive patients? Are you waiting for COVID-19 test results?
(Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment).

Yes

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* 5. Do you/have you had a fever or have you felt hot or feverish recently?
(the last 14-21 days)

Yes

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* 6. Are you having shortness of breath or other difficulties breathing? Have you experienced recent loss of taste or smell?

Yes

If yes, please indicate symptom below:

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* 7. Have you had any other flu-like symptoms such as a cough, gastrointestinal upset, headache or fatigue?

Yes

If yes, please specify below:

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* 8. Have you traveled in the past 14 days to any regions affected by COVID-19?
(as relevant to your location)

Yes

If yes, please indicate:

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* 9. Please call our office at 248-398-5545 when you arrive for your appointment. Please wait in your vehicle until directed to come in for your appointment. Please WEAR YOUR MASK into the office, stop at the front desk for a temperature check, and utilize our hand sanitizer to wash your hands. Thank you for helping keep everyone safe!

Date / Time

Date

Time

AM/PM

DR. DOLLAR PRE-APPOINTMENT COVID-19 PATIENT SCREENING FORM

Question Title

* 1. What is your first name?

Question Title

* 2. What is your LAST NAME INITIAL ONLY?

Question Title

* 3. What is your phone number?

Question Title

* 4. Are you in contact with any confirmed COVID-19 positive patients? Are you waiting for COVID-19 test results?(Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment).

Question Title

* 5. Do you/have you had a fever or have you felt hot or feverish recently?(the last 14-21 days)

Question Title

* 6. Are you having shortness of breath or other difficulties breathing? Have you experienced recent loss of taste or smell?

Question Title

* 7. Have you had any other flu-like symptoms such as a cough, gastrointestinal upset, headache or fatigue?

Question Title

* 8. Have you traveled in the past 14 days to any regions affected by COVID-19?(as relevant to your location)

Question Title

* 4. Are you in contact with any confirmed COVID-19 positive patients? Are you waiting for COVID-19 test results?
(Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment).

* 5. Do you/have you had a fever or have you felt hot or feverish recently?
(the last 14-21 days)

* 8. Have you traveled in the past 14 days to any regions affected by COVID-19?
(as relevant to your location)