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COVID-19 SCREENING QUESTIONNAIRE
ELISA L KUO DDS INC | (510) 834-4640
First Name
Last Name
Date Of Birth
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Are you/they having shortness of breath or other difficulties breathing?
Do you/they have a new cough, not related to allergies?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you/they experienced recent loss of taste or smell?
Are you/they in contact with any confirmed COVID-19 positive patients within the last 14 days?
Have you/they traveled in the past 14 days outside of California?
Where did you/they travel to?
Please upload your Covid-19 vaccination record here
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or drag files here
Have you/they been tested positive to COVID-19 in the last 30 days?
When did you/they test positive to COVID-19?
Have you/they been tested again with a negative result to COVID-19?
Please upload your negative test result here
Upload
or drag files here
Patients who are well but who have a sick family member at home with COVID-19 should postpone/reschedule treatment. "Yes" responses to any questions above would likely indicate a deeper discussion with our scheduling team before proceeding with dental treatment. Thank you for taking the time to complete this questionnaire.
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