Name

First Name

Last Name

Date of Birth

YYYY

Email or Phone Number

Please enter your preferred mode of contact in case we need to reach you.

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

Are you having shortness of breath or other difficulties breathing?

Do you have a cough?

Are you experiencing any 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?

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Is your age over 60?

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

Have you received the COVID-19 vaccine? (Either first or second dose)

Any additional comments, questions or remarks?

Positive responses to any of the above listed symptoms would likely indicate a deeper discussion with Dr. Wang before proceeding with elective dental treatment.

Please contact our office if you have any questions regarding COVID-19. (425) 485-8292

Hours
Monday: 8am-5pm
Tuesday: 9am-6pm
Wednesday: 8am-5pm
Thursday: 9am-6pm
Friday: 8am-2pm (1x/month)
Sat, Sun: Closed