Pre-Screening Form

Covid-19 Wellness Screening Form - 2020
Do you have a fever or have you felt feverish recently (the last 14-21 days)?
Are you having shortness of breath or other difficulties breathing?
Do you have a cough or have had a cough recently?
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 or have you been exposed to COVID-19?
Are you over the age of 60?
Do you have heart disease, lung disease, kidney disease,diabetes or any auto-immune disorders?

Have you traveled in the past 14 days? 

 
Please note: If you are not feeling well, we would like to request that you postpone or reschedule your appointment for another day when you feel better.

Contact Us

  • Bunnag Comprehensive Dentistry - 6501 Democracy Blvd., Bethesda, MD 20817 Phone: 301-896-0633
  • Silver Spring Office - 1400 Spring St., Suite 420, Silver Spring, MD 20910 Phone: 301-681-2969 Fax: 301-681-0214

Bethesda Office Hours

MON & WED: 8:00 a.m. - 5:30 p.m.

TUE & SAT: 8:00 a.m. - 2:00 p.m.

Silver Spring Office Hours

MON & WED: 8:00 a.m. - 5:00 p.m. (Administrative Days)

TUE & THU: 8:00 a.m. - 5:00 p.m.

FRI: By Appointment Only

Usa Bunnag D.D.S., P.A.

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