COVID-19 Patient Pre-Screening QuestionnairePlease enable JavaScript in your browser to complete this form.Name *FirstLastPhone: *Email *1. Do you have a fever or have felt hot or feverish anytime in the last 14 days? *YesNo2. Do you have any of these symptoms:New or worsening cough? New or worsening shortness of Breath?Difficulty breathing? Sore throat or painful swallowing?Runny nose?None of the above symptoms.3. Have you experienced a recent loss of smell or taste? *YesNo4. Have you been in contact with any confirmed COVID-19 positive patients or persons self-isolating because of a determined risk for COVID-19? *YesNo5. Have you returned from travel outside of Barbados in the last 14 days? *YesNo• If you answered "yes" to number 5 - where did you travel to?6. Is your workplace or occupation considered high risk? *YesNo7. Are you over the age of 65? *YesNo8. Have you been vaccinated with the COVID-19 vaccine? *YesNo9. Have you previously been tested positive for COVID-19? *YesNo• If you answered "yes" to number 9 – when were you tested positive?10. Are you in possession of a PCR test or Rapid Antigen test result? *YesNoIf your answer is "Yes" – Please present the test result to our front desk personnel on arrival at the office.11. Are you awaiting results from a PCR test or Raid Antigen test? *YesNo• If you answered "yes" to number 11 – when was the test taken?CommentsSignature:* To be signed upon arrival at Aesthetic Dental on the day of your appointment.Please Print Name - In All Capital Letters *FirstLastDate:* Enter the date on your arrival at Aesthetic Dental on the day of your appointment.SubmitCOVID-19 Patient Pre-Screening Questionnaire
