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Wellness Form

Do you have a cough?

YesNo

Do you have a fever now or have you in the past 14-21 days?

YesNo

Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?

YesNo

Are you experiencing shortness of breath or difficulty breathing?

YesNo

Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?

YesNo

Have you experienced recent loss of taste or smell?

YesNo

Are you over the age of 60?

YesNo

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

YesNo

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

YesNo

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Contact Our Practice

While Dr. Poiman strives to increase his knowledge in the field of dentistry and share it with his patients, he has created a warm and friendly environment where 'going to the dentist' is simply more fun.

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New York Office

57 W 57th St
Ste 605
New York, NY 10019

Open Today 8:00am - 5:00pm

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Contact Our Practice