First Name
Last Name
Email Address
Phone Number
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Are you/they having shortness of breath or other difficulties breathing?
Do you/they have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you/they experienced recent loss of taste or smell?
Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
Is your/their age over 60?
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
M & W: 8am - 5pmT: 9am - 6pmTh: 8am - 4pm
23961 Calle De La Magdalena #102, Laguna Hills, CA 92653
(949) 586-6030
