• Covid-19 Screening Questionnaire

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Covid-19 Test*
  • Covid-19 test results (check all that apply)
  • Date of Covid-19 test
     - -
    2 digit month, 2 digit day, 4 digit year
  • I am taking precautions and following the CDC recommendations. (check all that apply)*
  • Are you experiencing any of the following symptoms?*
  • Have you been in contact with anyone experiencing flu like symptoms?*
  • Have you been in contact with any confirmed with the Covic-19 positive patients?*

  • A MUST READ:

    Anyone experiencing flu like symptoms, has been with someone expieriencing flu like symptoms or has been with somone who has tested positive for the Covid-19 virus.

    1. Please call your physcian regarding your symptoms

    2. Please call the office and reschedule elective dental procedures.

    3. Please call the office if you are having a dental emergency

  • California and USA Travel- have you traveled to any of the following Covid-19 areas in the 14 to 30 days? Please check all that may apply.*
  • International Travel- have you traveled to any of the following Covid-19 areas in the 14 to 30 days? Please check all that may apply.*
  • Cruise Ship - Have you traveled on a cruise ship in the 14 to 30 days?*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: