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Patient Screening Form 
Do you/they have a fever or have you/they felt hot or feverish recently (14-21 days)
Are you/they having shortness of breath or other difficulties breathing?
Do you/they have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you/they experienced recent loss of taste or smell?
Are you/they in contact with any confirmed COVID-19 positive patients?

(Patients who are well but who have a sick family member of home with COVID-19 should consider postponing elective treatment.)

Is your/their age over 60?
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you/they traveled in then past 14 days to any regions affected by COVID-19 (as relevant to your location)

Positive responses to any of these would likely indicate 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 are's information.

Thanks for submitting!

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