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 a front line worker? • If "Yes", please state your place of employment and profession. *YesNoPlace of employment:Profession:8. Are you over the age of 65? *YesNo9. Have you been vaccinated with the COVID-19 vaccine? *YesNo10. Have you previously been tested positive for COVID-19? *YesNo• If you answered "Yes" to number 10 – when were you tested positive?11. 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.12. Are you awaiting results from a PCR test or Raid Antigen test? *YesNo• If you answered "Yes" to number 12 – when was the test taken?Comments:Signature:* 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.Submit COVID-19 Patient Pre-Screening Questionnaire
