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FORM #1 - Respiratory Illness Screening Form - Alison Jackson DDS
Please complete the following form before you arrive for your appointment (within 24 hrs.) Press submit when you are finished and the form will upload to our office. If you have any questions please call our office at 831-662-2900.
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자세히 알아보기
* 표시는 필수 질문임
Date of upcoming APPOINTMENT:
YYYY
/
MM
/
DD
Patient's first name:
*
내 답변
Patient's last name:
*
내 답변
Parent/Guardian's first and last name:
*
내 답변
Does your child have a fever or above-normal temperature (>100.4° F)?
*
Yes
No
필수
Is your child experiencing shortness of breath or having trouble breathing?
*
Yes
No
필수
Does your child have a dry cough?
*
Yes
No
필수
Does your child have a runny nose?
*
Yes
No
필수
Does your child have a sore throat?
*
Yes
No
필수
Is your child experiencing chills or repeated shaking with chills?
*
Yes
No
필수
Does your child have unexplained muscle pain?
*
Yes
No
필수
Does your child have a headache?
*
Yes
No
필수
Even if your child doesn't currently have any of the above symptoms, have they experienced any of these symptoms in the last 14 days?
*
Yes
No
필수
Has your child tested positive for COVID-19 in the last 14 days
*
Yes
No
필수
𝗣𝗮𝗿𝗲𝗻𝘁/𝗚𝘂𝗮𝗿𝗱𝗶𝗮𝗻 𝗦𝗶𝗴𝗻𝗮𝘁𝘂𝗿𝗲 - By entering your full name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.
*
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