Covid-19 In-Office Screening Are you a patient of ? Broad and Bright Serene Smiles Patient Name* Date of Birth* MM slash DD slash YYYY Email* Phone Number with area code*Type of Appointment*CleaningConsultationEmergencyOtherAppointment Date* MM slash DD slash YYYY Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?* Yes No Are you / they having shortness of breath or other difficulties breathing?* Yes No Do you/they have a cough?* Yes No Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?* Yes No Have you/they experienced recent loss of taste or smell?* Yes No 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.Pre-Appointment* Yes No Is your/their age over 60?* Yes No Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?* Yes No Have you/they traveled in the past 14 days to any regions affected by COVID-19?* Yes No Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.CommentsThis field is for validation purposes and should be left unchanged. Δ
