Address:
Crystal Lake
850 Munshaw Ln
Crystal Lake, IL 60014

Phone:
(815) 459-7400

Hours:
Mon, Tue, Thu: 8:00AM-4:00PM
Wed, Fri: 8:00AM-3:00PM

Contact Us

COVID-19 Risk Assessment

Patient Name

Phone Number

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

Have you traveled out of Illinois or northeast Illinois in the last 14 days?

Yes

If yes, where have you traveled?

Have you been in contact with anyone who has traveled to Illinois or northeast Illinois from somewhere else?

Yes

If yes, from where?

In the past 7 days have you had...

Any fever reducer medication(s), such as but not limited to, Tylenol®, Motrin®, ibuprofen and aspirin?

Yes

If yes, provide reason:

Temperature of 100.0 or above?

Yes

Shortness of breath or trouble breathing?

Yes

Loss or decrease in your sense of taste and/or smell?

Yes

Any of the following symptoms? If yes, check all that apply:

Cough

Chills

Runny nose

Headache

Sore throat

Muscle pain

I agree to contact Lehman & Menis Dental Implant and Oral Surgery Specialists if I develop any of these symptoms within 14 days of my last visit to an OMS office.

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Last Name

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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.