Patient Screening Form

Patient Full Name*

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?

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?

Have you/they traveled in the past 14 days to any regions affected?

Which HD Ortho Office location will you visit?*