covid-19 pre-screening questionnaire

FOR EVERY 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.

Parkview Dental Care is located in Chicago, IL. Our office is in compliance with Chicago's Emergency Travel Order for COVID-19. If anyone is coming from or personally interacted with someone from a state marked "high-risk" for Chicago during the time period that state is on the Emergency Travel Order; we request the appointment be scheduled 14 days AFTER returning or interacting with someone from that state. This is for the safety and protection of ALL of our patients and team. We appreciate your respect for our new protocols. Please refer to the list of states and details on the following link. https://www.chicago.gov/city/en/sites/covid-19/home/emergency-travel-order.html

Name*

Email*

If you get tested for COVID-19 between now and when you come in for your dental appointment, will you please contact us BEFORE coming to the office?*

(In the last 14 days) Have you or someone in your household personally interacted with someone from another state? If so, what state? and date?*

(In the last 14 days) Have you or someone in your household traveled outside of Illinois? If yes, what state and date? *

(In the last 14 days) Have you visited or been in a hospital or nursing home? If yes, what date and please explain:*

(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) Do you have a cough?*

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

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

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

Is someone in your household feeling sick? If yes, please explain their symptoms:*

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 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