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*
Appointment 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.
Email

Have questions? Let's talk!

Has it been awhile since you’ve been to the dentist? Maybe you’d like to know your treatment options or the ins and outs of a procedure? No problem! At Serene Smiles, we want to educate you on how good oral health can benefit your body and mind, and give you the confidence to smile your brightest!

Contact

(614) 568-3909

6357 Hamilton Road, Ste C
Westerville, Ohio 43081

MON: 9:00am – 5:00pm
TUE: 9:00am – 7:00pm
WED: 9:00am – 5:00pm
THU: 9:00am – Noon
FRI: 9:00am – 5:00pm
SAT: By Appointment Only

Website by Wonderist Agency

(614) 568-3909

Covid-19 In-Office Screening

Covid-19 In-Office Screening

Have questions? Let's talk!

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Contact