COVID-19 Questionnaire

I fully understand and acknowledge that the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By entering my name, I acknowledge that the answers I have provided are true and correct.

Monday	8:30am	-	4:00pm
Tuesday*	8:30am	-	4:00pm
Wednesday	8:30am	-	4:00pm
Thursday	8:30am	-	4:00pm

Fremont Family Dentistry

Family and Implant Dentistry Fremont, NC

(919) 242-5500

Fremont Family Dentistry

Family and Implant Dentistry Fremont, NC

COVID-19

COVID-19 PATIENT DISCLOSURES

Do you have a fever or above normal temperature? Yes No
Have you experienced shortness of breath or had trouble breathing? Yes No
Do you have a dry cough? Yes No
Do you have a runny nose? Yes No
Have you recently lost or had a reduction in your sense of smell? Yes No
Do you have a sore throat? Yes No
Have you been in contact with anyone who has tested positive for COVID-19? Yes No
Have you ever tested positive for COVID-19? Yes No
Have you been tested for COVID- 19 but still awaiting results? Yes No
Have you traveled outside the US in the past 14 days? Yes No