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Do you have fever or have you felt hot or feverish recently (14-21 days)?
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Are you having shortness of breath or other difficulties breathing?
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Do you have a cough?
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Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
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Yes
Have you experienced recent loss of taste or smell?
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Yes
Are you 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.
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Yes
Is your age over 60?
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Yes
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
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Yes
Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
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No
Yes
HIPAA ACKNOWLEDGEMENT Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold the requested Dental Office, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties. By selecting yes, I acknowledge my understanding of the HIPAA Policy and agree with its contents.
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