1310 Warwick Lincoln Park, MI 48146 | (313) 386-7660 | info@drmikeizzo.com NEW PATIENTS

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Dentist in Lincoln Park, Downriver, MI | Dr. Michael A. Izzo, D.D.S.

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COVID-19 Questionnaire

Name*
First Last
Email*
Phone*
Date of Birth*
Current Age*
Have you ever been diagnosed with COVID-19?*
- Yes
- No
Do you live with or care for someone who has COVID-19?*
- Yes
- No
Have you had a fever greater than or equal to 100.4 F degrees in the past 48 hours?*
- Yes
- No
Do you have a sore throat?*
- Yes
- No
Do you have a cough?*
- Yes
- No
Are you experiencing any shortness of breath or difficulty breathing?*
- Yes
- No
Have you recently lost your sense of taste/smell?*
- Yes
- No
Have you experienced vomiting or loose stools recently?*
- Yes
- No
Do you have a headache, body, or muscle aches?*
- Yes
- No
Have you traveled outside of the US in the past 14 days?*
- Yes
- No
Where have you traveled to?*
Do you have heart, kidney, or lung disease?*
- Yes
- No
Do you have any other condition that might increase your risk of infection such as cancer or diabetes?*
- Yes
- No

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SCHEDULE AN APPT.

Michael Izzo, D.D.S.

HOURS

Monday 9 am- 7 pm
Tuesday 9 am - 5 pm
Wednesday Closed
Thursday 10 am - 6 pm
Friday 9 am - 3 pm
Closed on Saturday and Sunday

CONTACT US

Address: 1310 Warwick Lincoln Park, MI 48146
Phone: (313) 386-7660
Fax: (313) 386-8980
Email: info@drmikeizzo.com

©2024 Dr. Michael A. Izzo, D.D.S. | Website by Ellanyze

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