{"id":1525,"date":"2020-06-08T18:18:01","date_gmt":"2020-06-08T18:18:01","guid":{"rendered":"http:\/\/northjerseyrootcanals.com\/?page_id=1525"},"modified":"2022-02-05T22:14:09","modified_gmt":"2022-02-05T22:14:09","slug":"covid-19-questionaire","status":"publish","type":"page","link":"https:\/\/northjerseyrootcanals.com\/index.php\/covid-19-questionaire\/","title":{"rendered":"Covid-19 Questionaire"},"content":{"rendered":"\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large is-resized\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/northjerseyrootcanals.com\/wp-content\/uploads\/2022\/02\/ADA-Patient-Screening-Form-1024x147.jpg\" alt=\"\" class=\"wp-image-1581\" width=\"724\" height=\"103\" srcset=\"https:\/\/northjerseyrootcanals.com\/wp-content\/uploads\/2022\/02\/ADA-Patient-Screening-Form-1024x147.jpg 1024w, https:\/\/northjerseyrootcanals.com\/wp-content\/uploads\/2022\/02\/ADA-Patient-Screening-Form-300x43.jpg 300w, https:\/\/northjerseyrootcanals.com\/wp-content\/uploads\/2022\/02\/ADA-Patient-Screening-Form.jpg 1438w\" sizes=\"auto, (max-width: 724px) 100vw, 724px\" \/><\/figure><\/div>\n\n\n\n<p class=\"has-text-align-center has-very-dark-gray-color has-text-color\" style=\"font-size:17px\"><strong>Please complete this questionnaire and submit to our office<\/strong>.<\/p>\n\n\n\n<h4 class=\"has-text-align-center has-vivid-red-color has-text-color wp-block-heading\" id=\"it-is-necessary-for-you-to-complete-this-form-to-hold-your-appointment-if-you-have-any-difficulty-completing-or-submitting-this-form-please-contact-our-office-during-normal-business-hours\"><strong>It is necessary for you to complete this form to hold your appointment.<\/strong><br>If you have any difficulty completing or submitting this form, <br>please contact our office during normal business hours.<\/h4>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-9d6595d7 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:25%\"><\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:50%\">\r\n<style type=\"text\/css\">\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field input[type=text],\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field input[type=email],\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field input[type=tel],\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field input[type=url],\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field input[type=password],\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field input[type=number]\r\n\t{\r\n\t\t\t\tborder-width: 1px;\t}\r\n\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field .wpforms-field-row\r\n\t{\r\n\t\t\t}\r\n\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field-layout.wpforms-field input[type=text],\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field-layout.wpforms-field input[type=email],\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field-layout.wpforms-field input[type=tel],\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field-layout.wpforms-field input[type=url],\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field-layout.wpforms-field input[type=password],\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field-layout.wpforms-field input[type=number]{\r\n\t\twidth: 100%;\r\n\t}\r\n\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field .wpforms-field-row input[type=text]{\r\n\t\twidth: 100%;\r\n\t}\r\n\r\n\r\n\r\n\r\n\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field textarea {\r\n\t\t\t\t\tborder-width: 1px;\t}\r\n\r\n\r\n \r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field-radio li label,\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field-payment-multiple li label {\r\n\t\tfont-weight: bold;color:#000000 ;\t}\r\n \r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field-checkbox li label {\r\n\t\tcolor:#dd3333 ;\t}\r\n \r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field .wpforms-field-description {\r\n\r\n\t\t\t}\r\n\r\n \r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field label.wpforms-field-label,\r\n\tbody #wpforms-1524 .wpforms-form .wpforms-field .wpforms-field-label {\r\n\t\tfont-weight: bold;font-size:15px;\t}\r\n\r\n\r\n\/* Styling for Tablets *\/\r\n@media only screen and (max-width: 800px) and (min-width:481px) {\r\n\t\r\n\r\n\r\n\r\n}\r\n\r\n@media only screen and (max-width: 480px){\r\n\t\r\n\r\n\r\n\r\n}\r\n\/*Option to add custom CSS *\/\r\n\r\n\r\n\r\n\t\t<\/style>\r\n\t\t<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-1524\"><form id=\"wpforms-form-1524\" class=\"wpforms-validate wpforms-form\" data-formid=\"1524\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/1525\" data-token=\"899e2d5a9e1760f56aa8229497ea329a\" data-token-time=\"1776933948\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-1524-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1524-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-1524-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1524-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" required><label for=\"wpforms-1524-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-1524-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-1524-field_1\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1524-field_1\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-1524-field_3-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-1524-field_3\">Cell Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-1524-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" step=\"any\" required><\/div><div id=\"wpforms-1524-field_40-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"40\"><label class=\"wpforms-field-label\">HAVE YOU HAD or been diagnosed with COVID-19 or RSV IN THE LAST 21 DAYS? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1524-field_40\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_40_1\" name=\"wpforms[fields][40]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_40_1\">Yes<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_40_4\" name=\"wpforms[fields][40]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_40_4\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-1524-field_70-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-1524-field_70\">IF YES, WHEN? WHEN DID SYMPTOMS STOP? <\/label><input type=\"text\" id=\"wpforms-1524-field_70\" class=\"wpforms-field-medium\" name=\"wpforms[fields][70]\" ><\/div><div id=\"wpforms-1524-field_7-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"7\"><label class=\"wpforms-field-label\">HAVE YOU OR ANYONE WITH WHOM YOU ARE IN CLOSE CONTACT HAD ANY SYMPTOMS OF COVID-19, RSV or COLD\/ FLU LIKE SYMPTOMS THAT YOU WOULD NORMALLY IGNORE IN THE LAST 14 DAYS <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1524-field_7\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_7_1\" name=\"wpforms[fields][7]\" value=\"Yes (which symptoms)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_7_1\">Yes (which symptoms)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_7_2\" name=\"wpforms[fields][7]\" value=\"No (skip to next question)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_7_2\">No (skip to next question)<\/label><\/li><\/ul><\/div><div id=\"wpforms-1524-field_42-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"42\"><label class=\"wpforms-field-label\">If yes, please tell us which symptoms?<\/label><ul id=\"wpforms-1524-field_42\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_42_1\" name=\"wpforms[fields][42]\" value=\"Fever or chill\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_42_1\">Fever or chill<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_42_4\" name=\"wpforms[fields][42]\" value=\"Cough\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_42_4\">Cough<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_42_5\" name=\"wpforms[fields][42]\" value=\"Fatigue\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_42_5\">Fatigue<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_42_7\" name=\"wpforms[fields][42]\" value=\"Muscle or body ache\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_42_7\">Muscle or body ache<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_42_8\" name=\"wpforms[fields][42]\" value=\"Headache\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_42_8\">Headache<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_42_9\" name=\"wpforms[fields][42]\" value=\"New loss of taste or smell\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_42_9\">New loss of taste or smell<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_42_10\" name=\"wpforms[fields][42]\" value=\"Sore Throat\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_42_10\">Sore Throat<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_42_12\" name=\"wpforms[fields][42]\" value=\"Nausea or vomiting\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_42_12\">Nausea or vomiting<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_42_13\" name=\"wpforms[fields][42]\" value=\"Congestion or runny nose\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_42_13\">Congestion or runny nose<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_42_14\" name=\"wpforms[fields][42]\" value=\"Diarrhea\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_42_14\">Diarrhea<\/label><\/li><\/ul><\/div><div id=\"wpforms-1524-field_51-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-1524-field_51\">IF YES, PLEASE GIVE DETAILS<\/label><input type=\"text\" id=\"wpforms-1524-field_51\" class=\"wpforms-field-medium\" name=\"wpforms[fields][51]\" ><\/div><div id=\"wpforms-1524-field_24-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"24\"><label class=\"wpforms-field-label\"> ARE THERE ANY OTHER MEDICAL CONCERNS or ISSUES THAT WE SHOULD BE AWARE OF TO PROTECT YOU, OTHER PATIENTS AND OUR STAFF <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1524-field_24\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_24_1\" name=\"wpforms[fields][24]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_24_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_24_2\" name=\"wpforms[fields][24]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_24_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-1524-field_39-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-1524-field_39\">IF YES, PLEASE GIVE DETAILS<\/label><input type=\"text\" id=\"wpforms-1524-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" ><\/div><div id=\"wpforms-1524-field_43-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"43\"><label class=\"wpforms-field-label\">We need you to confirm your appointment at this time. <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1524-field_43\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_43_1\" name=\"wpforms[fields][43]\" value=\"Yes, I am confirming my appointment \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_43_1\">Yes, I am confirming my appointment<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_43_2\" name=\"wpforms[fields][43]\" value=\"No, I am unable to make my appointment (Please call to reschedule) \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_43_2\">No, I am unable to make my appointment (Please call to reschedule)<\/label><\/li><\/ul><\/div><div id=\"wpforms-1524-field_44-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-1524-field_44\">Your appointment date (please add date \/ time)  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1524-field_44\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][44]\" required><\/div><div id=\"wpforms-1524-field_45-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"45\"><label class=\"wpforms-field-label\">Which office is your appointment? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1524-field_45\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_45_1\" name=\"wpforms[fields][45]\" value=\"Kinnelon Office\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_45_1\">Kinnelon Office<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1524-field_45_2\" name=\"wpforms[fields][45]\" value=\"Wayne Office\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1524-field_45_2\">Wayne Office<\/label><\/li><\/ul><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-1524-field-hp\" class=\"wpforms-field-label\">Message<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-1524-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v2\" ><div class=\"g-recaptcha\" data-sitekey=\"6LfFiwEVAAAAAAqsN0VR6oYSVls14cDc-esE9B-J\"><\/div><input type=\"text\" name=\"g-recaptcha-hidden\" class=\"wpforms-recaptcha-hidden\" style=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\" data-rule-recaptcha=\"1\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"1524\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/northjerseyrootcanals.com\/index.php\/wp-json\/wp\/v2\/pages\/1525\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-1524\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\n<\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:25%\"><\/div>\n<\/div>\n\n\n\n<p class=\"has-text-align-center\"><strong>Any questions please call Dr. Lubit @ 973- 633-1155 ~ Email us <a href=\"mailto:drlubit@gmail.com\" target=\"_blank\" rel=\"noreferrer noopener\">drlubit@gmail.com<\/a><\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Please complete this questionnaire and submit to our office. It is necessary for you to complete this form to hold your appointment.If you have any difficulty completing or submitting this &#8230;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"template-fullwidth.php","meta":{"om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-1525","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/northjerseyrootcanals.com\/index.php\/wp-json\/wp\/v2\/pages\/1525","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/northjerseyrootcanals.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/northjerseyrootcanals.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/northjerseyrootcanals.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/northjerseyrootcanals.com\/index.php\/wp-json\/wp\/v2\/comments?post=1525"}],"version-history":[{"count":20,"href":"https:\/\/northjerseyrootcanals.com\/index.php\/wp-json\/wp\/v2\/pages\/1525\/revisions"}],"predecessor-version":[{"id":1585,"href":"https:\/\/northjerseyrootcanals.com\/index.php\/wp-json\/wp\/v2\/pages\/1525\/revisions\/1585"}],"wp:attachment":[{"href":"https:\/\/northjerseyrootcanals.com\/index.php\/wp-json\/wp\/v2\/media?parent=1525"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}