COVID-19 Screening Questionnaire This questionnaire has been implemented as a precautionary measure to help us better serve you and keep you and our team safe; is not intended to suggest an immediate threat.Name* First Last Date of Birth* Screening questions must be answered prior to initiating any dental treatment:1. Do you, a family member or someone of whom you have close contact with, have or had the signs of acute respiratory illness such as coughing, fever and shortness of breath?*YesNo2. Do you have a fever?*YesNoIf so, have you taken any temperature readings?YesNo3. Have you, a family member or someone of whom you have close contact with, have or had any recent travel any locations designated by the CDC to have a Level 3 Travel Health Notice for COVID-19?*YesNoClick Here to View Locations Designated by the CDC to have a Level 3 Travel Health Notice for COVID-19If so when did you, a family member or someone of whom you have close contact with, returned to the United States? 4. Have you had close contact with an individual, such as a family member or co-worker, diagnosed with COVID-19 within the last 21 days?*YesNo
