www.nashuadentistry.com - Covid-19 Questionnaire

All patients must answer the following questions prior to any services being conducted. Answering yes will require the rescheduling of your appointment.

Name *

First Name Last Name

Have you had any of the following Covid -19 symptoms in the last 14 days *

A fever over 100.4 or felt feverish in the last 72 hours Respiratory symptoms including shortness of breath Any new muscle aches or chills Change in your sense of smell to taste I have experienced none of the above-mentioned symptoms of COVID – 19

Have you had close contact with someone who is suspected or confirmed to have COVID – 19 in the past 14 days? *

Yes No

Have you traveled in the past 14 days either internationally (outside the U.S) by cruise ship, or domestically (within the U.S) outside of NH, VT, or ME on public transportation (e.g. bus, train, plane)? *

Yes No

Please call the office (603) 880-3000 when you arrive to receive further instructions.