COVID‐19 PANDEMIC ‐ PATIENT SCREENING FORM
 
 
 Are you fully vaccinated for COVID-19?
 
 
 Do you have a fever or above normal temperature (>100.0 degree F)?


Are you experiencing more than one of the following symptoms: shortness of breath, dry cough, sore throat, unexplained muscle pain, headache or nausea, new loss of taste or smell?


Even if you don't currently have any of the above symptoms, have you experienced more than one of these symptoms in the last 14 days?
 
 
Have you been advised to quarantine due to close contact with someone diagnosed with COVID-19?
 

Have you been tested for COVID-19 in the last 14 days? 
I agree to notify Phillips Family Dental Care if within 2 days I become ill with COVID-19 symptoms or test positive for COVID-19.