501 Walnut Street
San Carlos, CA 94070
PH (650) 592-3436

Name:
Do you have a fever or above-normal temperature (>100.4° F)?
Are you experiencing shortness of breath or having trouble breathing?
Do you have a dry cough?
Do you have a runny nose?
Have you recently lost or had a reduction in your sense of smell or taste?
Do you have a sore throat?
Are you experiencing chills or repeated shaking with chills?
Do you have unexplained muscle pain?
Do you have a headache?
Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?
Have you been tested for COVID-19 in the last 14 days?
What is the result of the testing?
Have you traveled more than 100 miles from your home in the last 14 days?
I agree to notify the dental practice if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days.