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PATIENT SCREENING

FORM-COVID19

 

Patient Name:      

 

PRE-APPOINTMENT

IN-OFFICE

 

Date:      

Date:      

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

Yes   No

Yes   No

Are you/they having shortness of breath or other difficulties breathing?

Yes   No

Yes   No

Do you/they have a cough?

Yes   No

Yes   No

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

Yes   No

Yes   No

Have you/they experienced recent loss of taste or smell?

Yes   No

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

Yes   No

Is your/their age over 60?

Yes   No

Yes   No

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

Yes   No

Yes   No

Have you/they traveled in the past 14 days?

Yes   No

Yes   No

 

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment. 

 For testing, see the list of State and Territorial Health Department Websites for your specific area’s information

 

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Optimized Process
Optimized Process

Dear Patient,

 

We hope you and your family are in good health during these times of adjustment to Covid-19 prevention. Our commitment to your safety is our first priority.

 

Our office follows infection control recommendations made by the American Dental Association (ADA) the US Centers for Disease Control and Prevention (CDC), and the Occupational Safety and Health Administration (OSHA). We follow the activities of these agencies so that we are up- to- date on any new rulings or guidance that may be issued.

This office is open mostly during general business hours as we transition to dental practice with new Covid- 19 protocols established beginning 7/31/20.

Please text us at 6178825590@usamobility.net once you have arrived.

You must wear a face mask to enter the office.

If you have an appointment scheduled during the period of our closure, you will be rescheduled shortly. We thank you for your patience during this interruption and look forward to seeing you again when we reopen, happy and healthy. To make an appointment, please call or email the office.

If you have a true dental emergency please leave a detailed message at 6178825590@usamobility.net  or by phone at (978) 774-4505 and the doctor will be notified to reply to your call.

Sincerely,

 

Dr. Massod and Team

(978) 774-4505, Email:  lmdanvers@aol.com,  

Please visit www.wemakebeautifulsmiles.com

Dr. Massod's office is, and has been since before the advent of Covid 19,  equipped with top of the line industry standard CASCADE WHITE Air Purifier.

 

 
 

Surgically Clean Air's Cascade White Air Purifier is a Medical Grade Air System that is One of the Most Advanced on the Market.

 

MEDICAL-GRADE:

 
 
 
 

Clinical research study shows that the Surgically Clean Air Cascade White Air Purifier has excellent performance in Hospitals, Medical Labs and Dental Clinics to clean and sterilize the indoor air.

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Linda J Massod, DMD..P.C.
85 Constitution Lane , Suite 1A
We Make Beautiful Smiles
DANVERS, MA 01923
978-774-4505
978-762-7470 (fax)
lmdanvers@aol.com
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