COVID-19 Screening Ready to come in? Please complete COVID-19 screening form below. If you have any questions call us on (615) 348-1008. HiddenVersion history:v1.6 : CDC Guidelines about Quarantine updated (10 days) v1.5 : Thank you confirmation page (add), 2020-06-23 v1.3 : New header and No captcha (change), 2020-06-04Name:(* required) COVID-19 ScreeningDo you have a fever today or within the last 10 days?(* required) Yes No Are you having shortness of breath or other difficulties breathing?(* required) Yes No Do you have a cough?(* required) Yes No Do you have any other flu-like symptoms, such as gastrointestinal upset, headache/body ache or fatigue?(* required) Yes No Have you experienced recent loss of taste or smell?(* required) Yes No Have you been in direct contact with any confirmed COVID-19 positive people in the last 10 days?(* required) Yes No People who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.Positive responses to any of these COVID-19 questions would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment. SubmitAny questions?Please sign(* required) Reset signature Signature locked. Reset to sign again Important: You consent to sign this document electronically.