ADA Patient Screening Form

Azar & Kepic Periodontics & Dental Implants | 250 East 7th Street, Suite D, Upland CA, 91786 | 909-982-4169

Full Name:

Birthday:

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

Yes

Are you/they having shortness of breath or other difficulties breathing?

Yes

Do you/they have a cough?

Yes

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

Yes

Have you/they experienced recent loss of taste or smell?

Yes

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

Yes

Is your/their age over 60?

Yes

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

Yes

Have you/they traveled in the past 14 days to any regions affected by COVID-19 (as relevant to your location)?

Yes

Patient Validation:

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