• Patient Screening Form

  • Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
  • Do 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 at 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 the past 14 days to any regions affected by COVID-19? (as relevant to your location)
  • 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.

  • This field is for validation purposes and should be left unchanged.