COVID-19 Screening

COVID 19 Screening

We value our dental patients and assure you that your safety is our priority. We strive to provide you with quality dental care, while doing our part to prevent the spread of the Coronavirus.

Please fill the attached form and click the submit bottom one day before your appointment. Thank you.

Name *

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Last

Email *

Please inter your email address

Today's Date: *

Have you experienced any of the following symptoms in the past 48 hours: fever (100 degrees or higher) or chills, cough shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea *

Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with anyone who is known to have laboratory-confirmed COVID-19? *

Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with anyone who has any symptoms consistent with COVID-19? *

Within the past 14 days, have you traveled outside California or the United states? *

Attestation: *

I attest that my answers to the above questions are accurate.

Name *

First

Last