COVID-19 PRESCREENING (ENGLISH)

Miller Dental Arts

COVID-19 Pre-screening Form
Name*

First NameLast Name
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Email*
example@example.com
Which Miller Dental Arts office location is your appointment?*

West New York, New JerseyFort Lee, New Jersey

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:*

	YES	NO
Do you have a fever or above normal temperature?
Have you experienced shortness of breathe or had 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?
Do you have a sore throat?
Have you been in contact with someone who has tested positive for COVID-19?
Have you tested for COVID-19?
Have you been tested for COVID-19 and are awaiting results?
Have you traveled outside the United States by air or cruise ship in the past 14 days?
Have you traveled within the United States, by air, bus or train within the past 14 days?
Do you have a weakened immune system?
Are you currently undergoing treatment for cancer, such as chemotherapy or radiation therapy?
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.
Do you have an autoimmune disease such as Lupus, rheumatoid arthritis, multiple sclerosis, or psoriasis?
Do you have diabetes?
If so, do you have to take insulin injections?
Do you have asthma or COPD?

Explain any YES answers in the box below:
Signature (Use Your Finger): The answers you provided are true and accurate to the best of your knowledge: *

Clear
Should be Empty: