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2340 E. Stadium Blvd, Suite 7
Ann Arbor, MI 48104
(734) 973-0000
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Patient Screening Form

Patient Information

First Name: *

Last Name: *

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 gastronintestinal 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  

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.

 

Confirmation

 
 

Please wait, it may take a moment to submit your information.

 
The first step to a healthy beautiful smile is to schedule an appointment.
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for your whole family


Everwell Dentistry

2340 E. Stadium Blvd, Suite 7
Ann Arbor, MI 48104


Call
(734) 973-0000


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