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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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Dentist Burbank
Respected As A Patient

I continue to be impressed with every aspect of dental care and service at your office. Everyone is wonderful and makes me feel important, valued, and respected as a patient; everything is explained in detail.
-Shelley D.

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Toomin & Bieber, 3808 W Riverside Dr, Suite 408, Burbank, CA 91505 \ (818) 748-9998 \ \ 8/17/2022 \ Tags: burbank dentist, dental office, dentist burbank ca, dental office in burbank ca