Patient Screening Form

General Information

Patient Screening

Have you/they recently been tested for COVID-19?

Yes

No

Have you/they tested positive for COVID-19?

Yes

No

Do you/they have fever or have you/they felt hot or feverish recently (in the last 72 hours)?

Yes

No

Are you/they having shortness of breath or other difficulties breathing (in the last 72 hours)?

Yes

No

Do you have a cough?

Yes

No

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes

No

Have you/they experienced recent loss of taste or smell?

Yes

No

Are you/they in contact with any confirmed COVID-19 positive patients?

Yes

No

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?

International

Domestic

No

Have you been vaccinated?

Yes (first dose)

Yes (second dose)

No

If yes, please specify which vaccine you received

Johnson & Johnson

Moderna

Pfizer

Other

Have you received a booster?

Yes

No

Submit

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.

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