The Lowe Centre For Cosmetic and Implant Dentistry COVID-19 PATIENT EVALUATION FORM DateFirst NameLast NameDo you or have you had a fever of above 38°C or 100°F degrees in the past three days?YesNoHave you recently lost or had a reduction in your senses of smell or taste?YesNoDo you have a sore throat?YesNoDo you have a dry cough?YesNoDo you have a runny nose?YesNoHave you been in contact with someone who has tested positive for or suspected they were positive for Covid-19 (corona virus?) in the last two weeks?YesNoHave you tested positive for Covid-19 or are you awaiting test results for Covid-19 within the last 10 days?YesNoAre you in the high risk category being over the age of 70?YesNoDo you have any of the following: heart disease, high blood pressure, lung disease, kidney disease, diabetes, or any auto immune disorder?YesNoAre you currently taking any medications for any of the above conditions?YesNo Submit INTERESTED IN DENTAL BRIDGES? GET IN TOUCH
