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COVID-19 IN-OFFICE SCREENING FORM IN ABADIN DENTAL

COVID-19 In-Office Screening Form

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Name of Patient (First Name)*
Last Name
No to all the above?
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Do you/they have a fever or have you/they felt hot or feverish in the past 2 weeks (14-21 days)?
Are you/they having shortness of breath or other difficulties breathing?
Do you/they have a cough?

Do you/they have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you/they been in contact with someone confirmed positive with COVID-19 in the last two weeks (14-21 days)?
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)?

If other, please specify above
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Request Form

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Name*
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