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Patient Pre-Appointment Screening Form
Please follow the following steps to fill out the form and submit it electronically;
Name
*
First
Last
Email
*
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 gastrointestinal 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?
*
Yes
No
Is your/their age of 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
I believe that the information stated above is to be true to the best of my knowledge.
*
Yes
KEITH A. NORWALK D.D.S
103 W. FIFTH STREET
GENOA, OH 43430
419-855-4700
419-855-8333
kandostaff@drnorwalk.com
Business Hours
Monday: 8:00 AM - 5:00 PM
Tuesday: 8:00 AM - 5:00 PM
Wednesday: 8:00 AM - 5:00 PM
Thursday: 8:00 AM - 5:00 PM
Fri CLOSED
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