Name*Phone*Email* Do you have a fever or above-normal temperature (>100.4° F or 38° C)?*NoYesAre you experiencing shortness of breath or having trouble breathing?*NoYesDo you have a dry cough?*NoYesDo you have a runny nose?*NoYesHave you recently lost or had a reduction in your sense of smell or taste?*NoYesDo you have a sore throat?*NoYesAre you experiencing chills or repeated shaking with chills?*NoYesDo you have unexplained muscle pain?*NoYesDo you have a headache?*NoYesEven if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?*NoYesHave you been in contact with someone who has tested positive for COVID-19 in the last 14 days?*NoYesHave you been tested for COVID-19 in the last 14 days?*NoYesHave you traveled more than 100 miles from your home in the last 14 days?*NoYesI 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.PhoneThis field is for validation purposes and should be left unchanged.