COVID-19 Questionnaire

COVID-19 PATIENT DISCLOSURES

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19 virus.

It is also important that you disclose to this office ANY indication of having been exposed to COVID-19 or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

Please complete the form below and click “Submit Form”.
All fields are required.

Do you have a fever or above normal temperature?*
- Yes
- No
Have you experienced shortness of breath or had trouble breathing?*
- Yes
- No
Do you have a dry cough?*
- Yes
- No
Do you have a runny nose?*
- Yes
- No
Have you recently lost or had a reduction in your sense of smell?*
- Yes
- No
Do you have a sore throat?*
- Yes
- No
Have you been in contact with anyone who has tested positive for COVID-19?*
- Yes
- No
Have you ever tested positive for COVID-19?*
- Yes
- No
Have you been tested for COVID- 19 but still awaiting results?*
- Yes
- No
Have you traveled outside the US in the past 14 days?*
- Yes
- No
I fully understand and acknowledge the above information, and have disclosed to my provider any conditions in my health history.
By entering my name, I acknowledge that the answers I have provided are true and correct.
Name*
First Last
Phone*
Your Signature*
Name
This field is for validation purposes and should be left unchanged.

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Office Location

Jaffe Dental Group
20820 Telegraph Rd
Brownstown, MI 48174
Map & Directions

Phone: 734-479-4111

Cities We Serve

Brownstown, Grosse Ile, Riverview, Southgate, Taylor, Trenton, Woodhaven, Wyandotte

Office Hours

Monday:: 9:00 am – 6:00 pm
Tuesday:: 9:00 am – 6:00 pm
Wednesday:: 10:00 am – 7:00 pm
Thursday:: 8:00 am – 2:00 pm
Friday:: Closed
Saturday*:: 8:00 am – 2:00 pm
Sunday:: Closed

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