Patient Wellness Form - Southern Family Dental

First Name*

Last Name*

Phone*

Email*

Do you have a cough

Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?

Are you experiencing shortness of breath or difficulty breathing?

Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?

Are you over the age of 60?

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

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Phone

This field is for validation purposes and should be left unchanged.