Dentistry Bliss
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ADA COVID-19 Patient Screening Form

    PRE-APPOINTMENT

    ​IN-OFFICE


    Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

    Are you/they having shortness of breath or other difficulties breathing?

    ​Do you/they have a cough?

    Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

    Have you/they experienced recent loss of taste or smell?

    Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. 

    ​Is your/their age over 60?

    Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

    Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
    Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.  
    ​For testing, see the list of State and Territorial Health Department Websites for your specific area’s information.
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Dentistry Bliss

6332 Irvine Blvd
Irvine, CA 92620
(949) 654-1668
dentistrybliss6332@outlook.com

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  • Home
  • About
    • Tour The Office
  • Services
  • Technology
  • Initial Visit
  • Reviews
  • Contact
  • COVID-19 UPDATES