pre-screening questionnaire

UPON CONFIRMATION OF YOUR DENTAL APPOINTMENT, please answer the following questions (even your name & email). Our office needs your response at least 48 hours before you arrive for your dental appointment. THANK YOU!

Name*

Email*

Have you personally tested positive for COVID-19? If yes, when was the date and explain.*

Have you been in contact with a person who has tested positive for COVID-19? If yes, when was the date and explain.*

Do you have High Blood Pressure, Diabetes, Cancer, Heart Disease, Lung Disease, Kidney Disease or any Auto-Immune Disorders? If so, which one(s)?*

(In the last 14-21 days) Have you had flu-like symptoms, such as sore throat, muscle pain, headache, fatigue, chills, or gastrointestinal upset?*

(In the last 14-21 days) Do you have a cough?*

(In the last 14-21 days) Are you having shortness of breath or other difficulties breathing?*

(In the last 14-21 days) Have you experienced loss of taste or smell?*

(In the last 14-21 days) Do you have a fever or have you felt feverish?*

(In the last 14-21 days) Have you traveled outside of Illinois? If yes, when and what state?*

Worst case scenario, if you test positive for COVID-19, would you please inform us us? *

Thank you! Your privacy will be protected. Your reply comes to the office email.

Parkivew Dental Care reserves the right to postpone dental treatment to a patient if their symptoms deem necessary to postpone. Please be patient during this time of many changes.

Parkview Dental Care

4020 North Central Avenue, Chicago, Illinois 60634, United States

(773) 736-1406