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COVID-19 Screening Form

Your Name

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?

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?

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?

Thank you! Your answer is recorded.

Request an Appointment

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Q Smile Dental Spa - Quincy
235 Quincy Ave.

Quincy MA 02169
Phone: (617) 479-8400
Fax: (617) 479-8450

Opening Hours:
Sunday: Closed

Monday: 8:00 AM - 5:00 PM
Tuesday: 8:00 AM - 4:30 PM
Wednesday: 8:00 AM - 4:30 PM
Thursday: 8:00 AM - 4:30 PM
Friday: 8:00 AM - 4:30 PM

Saturday: 8:00 AM - 3:00 PM

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Smile With Confidence

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© 2020 Created by Q Smile Dental Spa. 

Q Smile Dental Spa - Randolph
482 S. Main St.

Randolph MA 02368
Phone: (617) 479-8420

Fax: (781) 805-8927
 
Opening Hours:
Sunday: Closed
Monday: Closed
Tuesday: 8:00 AM - 4:30 PM
Wednesday: 8:00 AM - 4:30 PM
Thursday: 8:00 AM - 4:30 PM
Friday: 8:00 AM - 4:30 PM
Saturday: 8:00 AM - 3:00 PM

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