ADA Patient Screening Form

First Name*

Last Name

Email*

Phone Number

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

Yes

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

Yes

Do you/they have a cough?

Yes

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

Yes

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

Yes

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

Is your/their age over 60?

Yes

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

Yes

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Yes

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

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Better dental care

for a better lifestyle!

Flourish Dental Boutique

Phone

(469) 908-8089

Address

1415 State Street Suite 800 Richardson, TX 75082

info@flourish.dental

Hours

Mon-Thu: 9:00-1:00, 2:00-5:00
Fri: 9:00-1:00
Sat-Sun: Closed

Flourish Dental Boutique Of Frisco

Phone

(469) 305-0052

Address

12850 Dallas Pkwy Ste 350, Frisco, TX 75033

frisco@flourish.dental

Hours

Mon-Thu: 9:00-1:00, 2:00-5:00
Fri-Sat-Sun: Closed

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hours

MON: 9:00-1:00, 2:00-5:00
TUE: 9:00-1:00, 2:00-5:00
WED: 9:00-1:00, 2:00-5:00
THURS: 9:00-1:00, 2:00-5:00
FRI: 9:00-1:00

Social Media

@Flourish Dental Boutique 2026

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Ready to get started?

Book your appointment today!

Better dental care

for a better lifestyle!

Flourish Dental Boutique

Flourish Dental Boutique Of Frisco

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Richardson, TX

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