Covid 19 Patient Screening Form

Covid 19 Patient Screening Form
Address *
Address
City
State/Province
Zip/Postal
These questions must be answered honestly under penalty of law. An answer of YES does not exclude you from treatment. Please answer YES or NO to each of the following questions:
Do you have a fever or above normal temperature? *
Do you have a runny nose? *
Have you recently lost or had a reduction in your sense of smell? *
Do you have a sore throat? *
Have you been in contact with someone who has tested positive for COVID-19? *
Have you tested for COVID-19? *
Do you have a weakened immune system? *

235 N. San Mateo Drive
Suite 300
San Mateo, CA 94401
Our Half Moon Bay, CA Orthodontist
705 Puissma St
Half Moon Bay, CA 94019
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