PATIENT COVID-19 SCREENING FORM

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Email *

Patient Name: *

Pre-Appointment Date: *

YYYY

Appointment Date: *

YYYY

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-immune disorders? *

YES

Other:

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.

I agree to notify the dental practice if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days.

AGREE

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