COVID-19 Questionnaire

I fully understand and acknowledge that the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By entering my name, I acknowledge that the answers I have provided are true and correct.

Monday	10:00am	-	7:00pm
Tuesday	8:00am	-	5:00pm
Wednesday	8:00am	-	1:00pm
Thursday	8:00am	-	4:00pm
Friday	8:00am	-	3:00pm

(609) 924-0936

COVID-19 Questionnaire

Patient Advisory and Acknowledgment

Receiving Dental Treatment During the COVID-19 Pandemic

Are you currently awaiting the results of a COVID-19 test? Yes No
Do you have a fever? Yes No
Do you have any shortness of breath? Yes No
Do you have a dry cough? Yes No
Do you have a runny nose? Yes No
Do you have a sore throat? Yes No
Do you have sneezing, watery eyes, and/or sinus pain/pressure that is unusual and not related to seasonal allergies? Yes No
Have you experienced headaches, fatigue, or weakness? Yes No
Have you lost your sense of taste and/or smell? Yes No
Within the last 14 days, have you travelled to any foreign country? Yes No
Within the last 14 days, have you travelled within the United States? Yes No