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Dental Prescreening -Form Fill

Section One

Name*

First Name

Name*

Last Name

Address*

Street Address

Address*

Street Address Line 2

Address*

City

Address*

State / Province

Address*

Postal / Zip Code

Primary Phone Number*

Phone Number

Alternate Phone Number

Phone Number

Q10

Email

Q11

These questions must be answered honestly under penalty of law. An answer of YES does not exclude you from treatment. Please answer YES or NO to each of the following questions:*

YES

Do you have a fever or above normal temperature?

Have you experienced shortness of breathe or had trouble breathing?

Do you have a dry cough?

Do you have a runny nose?

Have you recently lost or had a reduction in your sense of smell?

Do you have a sore throat?

Have you been in contact with someone who has tested positive for COVID-19?

Have you tested for COVID-19?

Have you been tested for COVID-19 and are awaiting results?

Have you traveled outside the Philippines by air or cruise ship in the past 14 days?

Have you traveled within the Philippines, by air, bus or train within the past 14 days?

Do you have a weakened immune system?

Are you currently undergoing treatment for cancer, such as chemotherapy or radiation therapy?

Do you take steroids for any conditions? Examples of common steroids are Cortisone, Prednisone, Methylprednisone. Contact your physician or our office if not sure. Also, answer YES if unsure.

Do you have an autoimmune disease such as Lupus, rheumatoid arthritis, multiple sclerosis, or psoriasis?

Do you have diabetes?

If so, do you have to take insulin injections?

Do you have asthma or COPD?

Q12

Explain any YES answers in the box below:

Q13

Dental Prescreening -Form Fill

Name*

Name*

Address*

Address*

Address*

Address*

Address*

Primary Phone Number*

Alternate Phone Number

Email

These questions must be answered honestly under penalty of law. An answer of YES does not exclude you from treatment. Please answer YES or NO to each of the following questions:*

Explain any YES answers in the box below:

Signature: By typing your name in the box below, you acknowledge that your answers you provided are true and accurate to the best of your knowledge: *