Patient Registration | Black Hills Pediatric Dentistry

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

Yes

No

Are you having shortness of breath or other difficulties breathing?

Yes

No

Do you have a cough?

Yes

No

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

Yes

No

Have you experienced recent loss of taste or smell?

Yes

No

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

Yes

No

Have you traveled outside the state of South Dakota in the past 14 days?

Yes

No

PRE-APPOINTMENT SCREENING