Please enable JavaScript in your browser to complete this form.Coronavirus (COVID-19) Patient Screening FormPatient Name *FirstLastEmail *Have you traveled outside the U.S. in the past 13 to 21 days? *NoYesIf yes, where? *Do you/they have a fever or have you/they felt hot or feverish recently (14-21 days)? *NoYesAre you/they having shortness of breath or other difficulties breathing? *NoYesDo you/they have a cough? *NoYesAny other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *NoYesHave you/they experienced recent loss of taste or smell? *NoYesAre you/they in contact with any confirmed COVID-19 positive patients? *NoYesPatients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.Is your/their age over 60? *NoYesDo you/they have heart disease, kidney disease, diabetes or any auto-immune disorders? *NoYesPlease explain: *MessageSubmit
