COVID-19 Pre-Screen Questionnaire

First Name*

Last Name*

Birthdate*

Contact Phone Number*

Email Address

In the past 14 days have you or your child traveled to any regions affected by Covid-19?*

No
Yes

Do you or have you had a fever of above 100 degrees in the past three days?*

No
Yes

Have you recently lost or had a reduction in your senses of smell or taste?*

No
Yes

Do you have a sore throat?*

No
Yes

Do you have a dry cough?*

No
Yes

Do you have a runny nose?*

No
Yes

Have you been in contact with someone who has tested positive for or suspected they were positive for Covid-19 (corona virus?) in the last two weeks?*

No
Yes

Have you tested positive for Covid-19 or are you awaiting test results for Covid-19 within the last 10 days?*

No
Yes

CAPTCHA

Pediatric Dental

Orthodontic

COVID-19 Pre-Screen Questionnaire