Name *

First Name

Last Name

Mobile Phone Number *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Date

MM

DD

YYYY

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

Yes

No

Are you/they having shortness of breath or other difficulties breathing?

Yes

No

Do you/they have a cough?

Yes

No

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes

No

Have you/they experienced recent loss of taste or smell?

Yes

No

Are you/they 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.

Yes

No

Is your/their age over 60?

Yes

No

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

Yes

No

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

Yes

No