773-904-7079
773-904-7079
Dental Services
CEREC (Same Day Crowns)
Cosmetic Dentistry
Teeth Whitening
Dental Veneers
Dental Implants
Orthodontics
Fillings and Extractions
Dentures And Partial Dentures
X Dental Implants
Dental Cleaning & Check Up
Dental Guards
Sleep Apnea Treatment
DENTAL SEALANTS
Dental X-RAY
Emergency Dental Care
Geriatric Dentistry
Laser Bacterial Reduction
Oral Cancer Screening
Pediatric Dentist
Periodontist
Porcelain Crowns, Bridges, Onlays, and Inlays
Root Canal
Sedation Dentistry
TMJ Treatment
Meet the Doctors
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Patient Forms
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Virtual Consult
Patient Screening Form
Patient Screening Form
Patient Name :
*
First
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days) ? (PRE-APPOINTMENT DATE)
*
YES
NO
Are you/they having shortness of breath or other difficulties breathing? (PRE-APPOINTMENT DATE)
*
YES
NO
Do you/they have a cough? (PRE-APPOINTMENT DATE)
*
YES
NO
Any other flu-like symptoms, such as gastrointestinal upset, headache or fattigue? (PRE-APPOINTMENT DATE)
*
YES
NO
Have you/they experienced recent loss of taste or smell? (PRE-APPOINTMENT DATE)
*
YES
NO
Have you/they come in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. (PRE-APPOINTMENT DATE)
*
YES
NO
Is your/their age over 60? (PRE-APPOINTMENT DATE)
*
YES
NO
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? (PRE-APPOINTMENT DATE)
*
YES
NO
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) (PRE-APPOINTMENT DATE)
*
YES
NO
Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
For testing, see the list of
State and Territorial Health Department Websites
for your specific area's information.
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