COVID-19 Pandemic Patient Questionnaire
If the answer is YES to any of the following questions, please reschedule your appointment.
Positive responses to any of the below questions would likely indicate a deeper discussion with your primary care provider before proceeding with elective dental treatment.
Have you had a fever above 100°F in the last 14-21 days?
Have you experienced recent loss of taste or smell?
Do you have shortness of breath or difficulty breathing?
Do you have or have had a cough in the last 14 days?
Do you have any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
Have you had contact with any COVID-19 positive patients?
Have you received a COVID-19 vaccine?
If yes, please select all that applies.

Thanks for submitting!