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

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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.

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