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Patient Screening Form

Patient Information

First Name: *

Last Name: *

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? *

Yes No  

Are you/they having shortness of breath or other difficulties breathing? *

Yes No  

Do you/they have a cough? *

Yes No  

Any other flu-like symptoms, such as gastronintestinal upset, headache or fatigue? *

Yes No  

Have you/they experienced recent loss of taste or smell? *

Yes No  

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. *

Yes No  

Is your/their age over 60? *

Yes No  

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? *

Yes No  

Have you/they traveled in the past 14 days to any regions affected by COVID-19 (as relevant to your location)? *

Yes No  

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

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




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24432 Muirlands Blvd. #201 Lake Forest, CA 92630-3939


(949) 837-8482


Mon - Thur: 9am - 6pm
Fri: Closed
SAT: 8am - 3pm
Sun: Closed

Copyright © 2019-2024 Jeanette Thai, DDS and WEO Media (Touchpoint Communications LLC). All rights reserved.  Sitemap
About Us | Dr. Jeanette Thai - Dentist in Lake Forest, CA
We are a dental practice devoted to restoring and enhancing the natural beauty of your smile using conservative, state-of-the-art procedures that will result in beautiful, long lasting smiles!
Jeanette Thai, DDS, 24432 Muirlands Blvd. #201, Lake Forest, CA 92630 + (949) 837-8482 + + 6/19/2024 + Tags: dentist Lake Forest CA +