1. Have you previously been diagnosed with COVID-19, or do you think you've had/have COVID-19? *
If NO to Question 1, skip to Question 5
2. If Yes, when and how were you confirmed positive?


3. If you have had COVID-19, how were you confirmed negative?
3. If you have had COVID-19, how were you confirmed negative?
4. If you have had COVID-19, when were you confirmed negative?

5. Do you currently have (or have you experienced) any of the following symptoms in the past 21 days?

Fever *
Fatique (feeling tired) *
Altered or loss of taste/smell *
Dry Cough *
Trouble breathing *
Shortness of breath, difficulty breathing, chest tightness *
Confussion *
Blueish lips or face *
Chills/Repeated shaking with chills *
Muscle pain *
Headache or soar throat *
Any other flu-like symptoms *
GI upset or diarrhea *
6. Are you in contact with anyone who has been sick/or confirmed to COVID-19 positive *
7. In the past 14 days have you traveled to any region affected by COVID-19? *
Some medical conditions have been associated with more severe COVID-19 disease. The following questions are an attempt to determine your risk:
8. Are you over age 65? *
9. Do you have high blood pressure? *
If you have high blood pressure, is it controlled?
10. Do you have diabetes? *
11. Are you overweight? *
13. Do you have any autoimmune disorders? *
14. Are there any other conditions you would like to report *
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.