Richard Oliver, DMD - COVID-19 Screening Form

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Email *

First Name: *

Last Name: *

Do you/they have fever or have you/they felt hot or feverish recently (Last 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? (Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.) *

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

A copy of your responses will be emailed to the address you provided.

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