Your Name (required)

Date (required)

Your Email (required)

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
yesno
Are you/the having shortness of breath or other difficulties breathing?
yesno
Do you/the have a cough?
yesno
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
yesno
Have you/the experienced recent loss of taste or smell?
yesno
Are you/the in contact with any confirmed COVID-19 positive patients?
yesno

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?
yesno
Do you/the have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
yesno
Have you/the traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
yesno

Positive response to any of these would likely indicate a deeper discussion before proceeding with elective treatment.

For testing, see the list of State and Territorial Health Department Websites for your specific area's information.