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Screening Form COVID-19
Queens Family Dentistry
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Full First and Last Name of who the appointment is for:
*
Your answer
Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating or staying at home?
*
Yes
No
In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?
*
If yes provide date
Yes
No
Other:
In the last 5 days have you experienced any of these symptoms?
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I agree, if I develop any of the symptoms listed or test positive for COVID-19, before my appointment I will notify Queens Family Dentistry.
Fever
New onset of cough / worsening chronic cough
Shortness of breath
Sore throat
Runny or stuffy/congested nose
Decrease or loss of sense of taste or smell
Fatigue, lethargy, malaise and/or myalgias
Nausea, vomiting and/or diarrhea
Headache
None
Other:
Required
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