Screening Questionnaire

Screening Questionnaire

Washington Screening

COVID-19 Screening Questionnaire

In following both CDC and ADA recommendations, this questionnaire is designed with your safety in mind. Your answers will be reviewed prior to your appointment and a member of our team will contact you if we recommend rescheduling to a later date. Thank you for your consideration and understanding.

Patient First Name

Patient Last Name

In the past 3 weeks, have you been in contact with anyone who is confirmed COVID-positive?

YesNo

Do you currently have any flu-like symptoms, such as fever, stomach upset, diarrhea, headache, or fatigue?

YesNo

Have you used public transportation in the past 14 days (including airplane, train, Metro, taxi, Uber, Lyft)?

YesNo

If you have received a COVID vaccine, please bring your card to your appointment. Card present?

YesNo

Is there anything else our team should know before treating you?

Relationship to the patient

Name if not the patient

Request an Appointment

First Name

Last Name

Phone

Preferred Date

How did you hear about us?

Other Referral

Message

Receive skincare tips and special offers

Call Us

(202) 628-8855

Service Area

Washington, DC