Skip to form

Beacon Oral & Maxillofacial Surgeons

24850 SE Stark St. Suite 100
Gresham, OR 97030

Other Locations
The Dalles

(503) 665-7882 – Gresham
(360) 256-7100 – Vancouver
(541) 296-7590 – The Dalles
(503) 654-3530 – Milwaukie

Mon–Fri: 8:00 AM–5:00 PM

Contact Us

ADA COVID-19 Risk Assessment form

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

Are you having shortness of breath or other difficulties breathing?

Do you have a cough?

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

Have you experienced recent loss of taste or smell?

Are you in contact with any confirmed COVID-19 positive patients?

Is your age over 60?

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

Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)