COVID-19 Screening

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *

Yes

Are you having shortness of breath or other difficulties breathing? *

Yes

COVID-19 Screening Form

Blood Disease

Yes

Arthritis/Grout

Yes

Are you in contact with any confirmed COVID-19 positive patients? *

Yes

Artificial Heart Disease

Yes

Thank you for your submission. We look forward to seeing you soon!

As of this week (8/5/21), we as a healthcare facility are required by the CDC to ask you these questions prior to your appointment.

At entry all patients are required to wear a mask or face covering. We ask you to call us from your car for preauthorization and temperature check (per CDC guideline).

Date *

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

Yes

Anaphylaxis

Yes

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my and other's health. It is my responsibility to inform the dental office of any changes. *

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

Yes

Asthma

Yes

"A smile is a little thing that makes a big difference!"

Anemia

Yes

Is your age over 60 years old? *

Yes

Have you experienced recent loss of taste or smell? *

Yes

Angina

Yes

Blood Transfusions

Yes

Do you have a cough? *

Yes

William S. Woodworth, D.D.S.

Call Us: 315-548-5141

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COVID-19 Screening

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