COVID-19 Questionnaire

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By entering my name, I acknowledge that the answers I have provided are true and correct.

Monday	9:00am	-	5:00pm
Tuesday	9:00am	-	5:00pm
Wednesday	9:000am	-	5:00pm
Thursday	9:00pm	-	5:00pm
Friday	By Appt Only

Premier Dentistry of Christiana

Gentle Care for Your Healthy Smiles

(302) 366-7636

Christiana Hospital
Medical Arts Pavilion 1
4745 Ogletown-Stanton Rd
Suite 110
Newark, DE, 19713

Premier Dentistry of Christiana

Gentle Care for Your Healthy Smiles

COVID-19 Questionnaire

Patient Advisory and Acknowledgment

Receiving Dental Treatment During the COVID-19 Pandemic

Are you fully vaccinated for COVID-19? Yes No
Do you have a fever or above normal temperature? Yes No
Have you experienced any shortness of breath or had trouble breathing? Yes No
Do you have a dry cough? Yes No
Do you have a runny nose? Yes No
Do you have a sore throat? Yes No
Have you recently lost or had a reduction in your sense of smell? Yes No
Have you been in contact with anyone who has tested positive for COVID-19? Yes No
Have you ever tested positive for COVID-19? Yes No
Have you been tested for COVID- 19 but still awaiting results? Yes No
Have you traveled outside the United States by air or cruise ship in the past 14 days? Yes No
Have you traveled within the United States, by air, bus or train within the past 14 days? Yes No If so, where?