Date of Birth
Do you 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 cough?
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?
Is your/their age over 60?
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
1020 Bay Area Blvd
Houston, TX 77058
Monday: 8AM – 5PM
Tuesday: 8AM – 3:30PM
Wednesday: 8AM – 5PM
Thursday: 8AM – 3:30PM
Friday – Sunday: Closed
New Patient Form
Coronavirus Screening Questionnaire
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