Covid-19 In-Office Screening Are you a patient of ?Broad and BrightSerene SmilesPatient Name*Date of Birth* Date Format: MM slash DD slash YYYY Email* Phone Number with area code*Type of Appointment*CleaningConsultationEmergencyOtherAppointment Date* Date Format: MM slash DD slash YYYY Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*YesNoAre you / they having shortness of breath or other difficulties breathing?*YesNoDo you/they have a cough?*YesNoAny other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*YesNoHave you/they experienced recent loss of taste or smell?*YesNoAre 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.Pre-Appointment*YesNoIs your/their age over 60?*YesNoDo you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*YesNoHave you/they traveled in the past 14 days to any regions affected by COVID-19?*YesNoPositive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.PhoneThis field is for validation purposes and should be left unchanged.
