PATIENT SCREENING
FORM-COVID19
Patient Name:
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PRE-APPOINTMENT
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IN-OFFICE
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Date:
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Date:
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Do you/they have fever or have you/they felt hot or feverish recently
(14-21 days)?
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Yes No
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Yes No
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Are you/they having shortness of breath or other difficulties breathing?
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Yes No
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Yes No
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Do you/they have a cough?
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Yes No
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Yes No
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Any other flu-like symptoms, such as gastrointestinal upset, headache
or fatigue?
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Yes No
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Yes No
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Have you/they experienced recent loss of taste or smell?
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Yes No
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Yes No
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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.
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Yes No
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Yes No
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Is your/their age over 60?
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Yes No
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Yes No
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Do you/they have heart disease, lung disease, kidney disease,
diabetes or any auto-immune disorders?
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Yes No
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Yes No
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Have you/they traveled in the past 14 days?
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Yes No
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Yes No
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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
Dr. Massod has again,for the 3rd year in a row, been designated one of Massachusetts Top Dentists by Boston Magazine for 2023.
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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
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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.
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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