El Dorado Family Dental-Covid-19 Questionnaire

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Covid-19 Questionnaire

El Dorado Family Dental

4944 Windplay Drive, 301,
El Dorado Hills, CA 95762
(530) 444-4944

In order to protect the safety of our providers, staff, and patients; please provide answers to all of the following questions before coming in for your scheduled appointment:

Patient Information( * mandatory to fill )

First Name *

Last Name *

Date of Birth *

Phone Number *

Email *

Gender *

Do you have a fever or above normal temperature? *

Have you experienced shortness of breath or had trouble breathing? *

Do you have a dry cough? *

Do you have a runny nose? *

Have you recently lost or had a reduction in your sense of smell? *

Do you have a sore throat? *

Have you been in contact with someone who has tested positive for COVID-19? *

Have you tested positive for COVID-19? *

Have you been tested for COVID-19 and are awaiting results? *

Have you traveled outside the United States by air or cruise ship in the past 14 days? *

Have you traveled within the United States by air, bus or train within the past 14 days? *

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