COVID-19 IN-OFFICE SCREENING FORM IN ABADIN DENTAL

COVID-19 In-Office Screening Form

"*" indicates required fields

Email

This field is for validation purposes and should be left unchanged.

Name of Patient (First Name)*

Last Name

Temperature of Patient

No to all the above?

No symptoms

Today's Date (Date of Appointment)

Do you/they have a fever or have you/they felt hot or feverish in the past 2 weeks (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

Other

Do you/they have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes

No

Have you/they been in contact with someone confirmed positive with COVID-19 in the last two weeks (14-21 days)?

Yes

No

Patients who are well but who have a sick family member at home with COVID-19 should consider rescheduling their appointment.

Do you/they have any pre-existing conditions, or auto-immune disorders (i.e. Heart Disease, Lung Disease, Kidney Disease, or Diabetes)?

Yes

No

Other

If other, please specify above

CAPTCHA