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Staying safe while visiting Serene Smiles during COVID-19!
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Covid-19 Pre-Appointment Screening
Covid-19 Pre-Appointment 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
*
Cleaning
Consultation
Emergency
Other
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
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