Patient Screening Form

General Information

Patient Screening

Have you/they recently been tested for COVID-19?
Have you/they tested positive for COVID-19?
Do you/they have fever or have you/they felt hot or feverish recently (in the last 72 hours)?
Are you/they having shortness of breath or other difficulties breathing (in the last 72 hours)?
Do you have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you/they experienced recent loss of taste or smell?
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.
Have you/they traveled in the past 14 days?
Have you been vaccinated?
If yes, please specify which vaccine you received


Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.