Access Dental Care COVID-19 Prescreening Form

Dr. Taraneh Tabatabaie

COVID-19 Pre-screening Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email
example@example.com
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?*

YesNo
Have you experienced shortness of breathe or had trouble breathing?*

YesNo
Do you have a dry cough?*

YesNo
Do you have a runny nose?*

YesNo
Have you recently lost or had a reduction in your sense of smell?*

YesNo
Do you have a sore throat?*

YesNo
Have you been in contact with someone who has tested positive for COVID-19?*

YesNo
Have you tested for COVID-19?*

YesNo
Have you been tested for COVID-19 and are awaiting results?*

YesNo
Have you traveled outside the United States by air or cruise ship in the past 14 days?*

YesNo
Have you traveled within the United States, by air, bus or train within the past 14 days?*

YesNo
Do you have a weakened immune system?*

YesNo
Are you currently undergoing treatment for cancer, such as chemotherapy or radiation therapy?*

YesNo
Do you take steroids for any conditions? Examples of common steroids are Cortisone, Prednisone, Methylprednisone. Contact your physician or our office if not sure. Also, answer YES if unsure.*

YesNo
Do you have an autoimmune disease such as Lupus, rheumatoid arthritis, multiple sclerosis, or psoriasis?*

YesNo
Do you have diabetes?*

YesNo
If so, do you have to take insulin injections?*

YesNo
Do you have asthma or COPD?*

YesNo
Explain any YES answers in the box below:
Signature: By signing your name in the box below, you acknowledge that your answers you provided are true and accurate to the best of your knowledge: *

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Dr. Taraneh Tabatabaie