[et_pb_section fb_built=”1″ _builder_version=”4.2.1″][et_pb_row column_structure=”3_5,1_5,1_5″ _builder_version=”4.2.1″][et_pb_column type=”3_5″ _builder_version=”4.2.1″][et_pb_text _builder_version=”4.2.1″]<\/p>\n
[\/et_pb_text][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.2.1″][et_pb_image src=”\/\/i0.wp.com\/antoinedentalcenter.com\/wp-content\/uploads\/2020\/04\/Antoine-Dental-Center-Square.png” _builder_version=”4.2.1″][\/et_pb_image][\/et_pb_column][et_pb_column type=”1_5″ _builder_version=”4.2.1″][et_pb_image src=”\/\/i0.wp.com\/antoinedentalcenter.com\/wp-content\/uploads\/2020\/04\/ada.png” _builder_version=”4.2.1″ background_color=”#373839″][\/et_pb_image][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.2.1″][et_pb_column type=”4_4″ _builder_version=”4.2.1″][et_pb_contact_form captcha=”off” email=”help@antoinedental.com” success_message=”Thank you for your submission.” submit_button_text=”Submit” _builder_version=”4.2.1″][et_pb_contact_field field_id=”Name” field_title=”Patient Name” _builder_version=”4.2.1″ button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off”][\/et_pb_contact_field][et_pb_contact_field field_id=”Email” field_title=”Email Address” field_type=”email” _builder_version=”3.16″ button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off”][\/et_pb_contact_field][et_pb_contact_field field_id=”Phone” field_title=”Phone” fullwidth_field=”on” _builder_version=”4.2.1″][\/et_pb_contact_field][et_pb_contact_field field_id=”In_office” field_title=”Are you filing this form out in-office or before your appointment?” field_type=”radio” radio_options=”%91{%22value%22:%22In-Office%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Pre-Appointment%22,%22checked%22:0,%22dragID%22:0}%93″ fullwidth_field=”on” _builder_version=”4.2.1″][\/et_pb_contact_field][et_pb_contact_field field_id=”Fever” field_title=”Do you\/they have fever or have you\/they felt hot or feverish recently (14-21 days)?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0}%93″ fullwidth_field=”on” _builder_version=”4.2.1″][\/et_pb_contact_field][et_pb_contact_field field_id=”Breathing” field_title=”Are you\/they having shortness of breath or other difficulties breathing?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0}%93″ fullwidth_field=”on” _builder_version=”4.2.1″][\/et_pb_contact_field][et_pb_contact_field field_id=”Sore_Throat” field_title=”Do you\/they have a cough or a sore throat?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0}%93″ fullwidth_field=”on” _builder_version=”4.2.1″][\/et_pb_contact_field][et_pb_contact_field field_id=”Flu” field_title=”Any other flu-like symptoms, such as gastrointestinal upset, nausea, diarrhea, headache or fatigue?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0}%93″ fullwidth_field=”on” _builder_version=”4.2.1″][\/et_pb_contact_field][et_pb_contact_field field_id=”Taste” field_title=”Have you\/they experienced recent loss of taste or smell?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0}%93″ fullwidth_field=”on” _builder_version=”4.2.1″][\/et_pb_contact_field][et_pb_contact_field field_id=”Contact” field_title=”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.” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0}%93″ fullwidth_field=”on” _builder_version=”4.2.1″][\/et_pb_contact_field][et_pb_contact_field field_id=”60″ field_title=”Is your\/their age over 60?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0}%93″ fullwidth_field=”on” _builder_version=”4.2.1″][\/et_pb_contact_field][et_pb_contact_field field_id=”Disease” field_title=”Do you\/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0}%93″ fullwidth_field=”on” _builder_version=”4.2.1″][\/et_pb_contact_field][et_pb_contact_field field_id=”Travel” field_title=”Have you\/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)” field_type=”radio” radio_options=”%91{%22value%22:%22Yes%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22No%22,%22checked%22:0,%22dragID%22:0}%93″ fullwidth_field=”on” _builder_version=”4.2.1″][\/et_pb_contact_field][\/et_pb_contact_form][et_pb_text _builder_version=”4.2.1″]<\/p>\n
Positive responses to any of these would likely indicate a deeper discussion with the dentist before
proceeding with elective dental treatment.<\/p>\n
[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"
Patient Screening FormPositive responses to any of these would likely indicate a deeper discussion with the dentist beforeproceeding with elective dental treatment. For testing, see the list of State and Territorial Health Department Websites for your specific area\u2019s information.<\/p>","protected":false},"author":4,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"class_list":["post-51805","page","type-page","status-publish","hentry"],"yoast_head":"\n