Questions to be Answered Prior to Return to Dr. Wei Dental Clinic During Coronavirus Infection

Name:

Birthday:

Have you contracted COVID19 (Yes/No) or contacted with anybody diagnosed with COVID19 (Yes/No)?

Do you have fever (Yes/No), runny nose (Yes/No), sneezing (Yes/No), cough (Yes/No), Loss of smell or taste (Yes/No) or raspy voice (Yes/No)?

2020/   /    Sign____________________

Text the form at 770-814-2282.  Thanks.

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Xin Wei, DDS, PhD, MS 1st edition 04/20/2020, last revision 04/24/2020