Dr. Michael Clark

Patient Name*

First NameMiddle NameLast Name

Preferred Name

Do you have or have you felt hot or feverish recently (14-21 days)?*

YesNo

Are you having shortness of breath or other difficulties breathing?*

YesNo

Do you have a cough?*

YesNo

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

YesNo

Are you in contact with any confirmed COVID-19 positive patients?*

YesNo

If yes, please explain below:

Do you have heart disease, lung disease, kidney disease, diabetes or auto-immune disorders?*

YesNo

If yes, please specify below:

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

YesNo

If yes, please state where and the nature of your visit?** Please note that if you have traveled outside of the U.S. we will need to wait 14 days for your next appointment.

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

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Patient Information