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About
Blog
Careers
Dr. Jinyoung Kim
Dr. Shelby Oberst
Dr. Allison Travis
Meet the Team
Dental Savings Plan
Recommended Dental Health Products
Reviews
Restorative Dentistry
Bridges
Crowns
Dental Implants
Tooth Extractions
Root Canal
Headache Relief
Jaw Muscle and Joint Pain(TMD)
Snore Prevention
Tongue Ties & Lip Ties
General Dentistry
Advanced Dental Technology
Hygiene and Periodontal Health
Sedation
Cosmetic Dentistry
Botox & Filler
Clear Aligners
Lumineers
Bonding and White Fillings
Patient Resources
Dental Savings Plan
New Patient Forms
Post-Op Instructions
Contact
Pay My Bill
About
Blog
Careers
Dr. Jinyoung Kim
Dr. Shelby Oberst
Dr. Allison Travis
Meet the Team
Dental Savings Plan
Recommended Dental Health Products
Reviews
Restorative Dentistry
Bridges
Crowns
Dental Implants
Tooth Extractions
Root Canal
Headache Relief
Jaw Muscle and Joint Pain(TMD)
Snore Prevention
Tongue Ties & Lip Ties
General Dentistry
Advanced Dental Technology
Hygiene and Periodontal Health
Sedation
Cosmetic Dentistry
Botox & Filler
Clear Aligners
Lumineers
Bonding and White Fillings
Patient Resources
Dental Savings Plan
New Patient Forms
Post-Op Instructions
Contact
Pay My Bill
(859) 273-5020
COVID-19 FORM
LEXINGTON, KENTUCKY
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Patient Screening Form
Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Yes
No
Are you/they having shortness of breath or other difficulties breathing?
Yes
No
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Yes
No
Do you/they have a cough?
Yes
No
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Yes
No
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.
Yes
No
Is your/their age over 60?
Yes
No
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
Yes
No
Have you/they experienced recent loss of taste or smell?
Yes
No
I understand the risk of keeping my appointment and having treatment completed with the COVID-19 spreading. I understand all of this and still accept the risk and want to continue my treatment today.
Yes
No
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