COVID-19 Risk Assessment

Patient Name

Phone Number

Have you had a fever, cough, shortness of breath, sore throat, any new loss of smell or taste, muscle pain, or flu-like symptoms in the past 14 days?

Yes

No

Have you been near or had physical contact with anyone who has had these symptoms or has been diagnosed with COVID-19 in the past 14 days?

Yes

No

Have you traveled out of Texas in the last 14 days?

Yes

No

If yes, where have you traveled?

Have you been in contact with anyone who has traveled to Texas from somewhere else?

Yes

No

If yes, from where?

I agree to contact Alfi Oral, Dental Implant & Facial Surgery if I develop any of these symptoms within 14 days of my last visit to the office.

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First Name

Last Name

Email

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I agree to electronically sign and to create a legally binding contract between the other party and myself or the entity I am authorized to represent.

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