covid-19 pre-screening questionnaire

FOR EVERY DENTAL APPOINTMENT - Please answer the following questions (even your name & email). Our office needs your response as soon as possible, at least 48 hours before you arrive for your dental appointment.

Regardless of receiving the COVID vaccine or not, we still require your response.

If you prefer to answer the questions over the phone, please call us and we'll go over them with you: 773-736-1406.

Name*

Email*

If you happen to get tested for COVID19 between now and when you come in for your dental appt, will you please contact us BEFORE coming to the office?*

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

(In the last 14 days) Have you had a fever or have you felt feverish?*

(In the last 14 days) Please list any symptoms you have experienced: cough, difficulties breathing, loss of taste or smell or NONE of the above?*

If symptoms should appear (with you or someone in your household) between now and when you come in, would you contact us BEFORE coming to the office?*

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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 or circumstances 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

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