Patient Screening Form

General Information

Patient Screening

Have you/they tested positive for COVID-19?

Yes

No

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

Yes

No

Are you/they having shortness of breath or other difficulties breathing?

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.

Do you/they have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?

Yes

No

Have you/they traveled out of the United States recently?

Yes

No

Please Note: Falsification of this form can be punishable by law.

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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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