Patient Screening Form

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Please fill out the following form a week before your dental appointment or it may need to be rescheduled.

Please type your full name. *

What date and time is your next appointment? *

Has your dental insurance recently changed?

Yes

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If your insurance info has changed please provide new info below and allow us to make a copy of your card. *

Do you or anyone you have been around have/had a fever or have felt hot/feverish in the last 14/21 days? *

Yes

Are you having shortness of breath or difficulties breathing? *

Yes

Do you have a NEW dry cough or sore throat that is not caused by allergies? *

Yes

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

Yes

Have you experienced recent loss of taste or smell? *

Yes

Have you been in contact with any confirmed COVID-19 cases within the last 21 days? *

Yes

Have you been in contact with anyone awaiting a COVID-19 test or being quarantined.

Yes

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Have you been diagnosed with COVID-19? *

Yes

If diagnosed, have you tested negative with follow-up testing? *

Yes

N/A- I have not tested positive

Have you personally or have you been around anyone that has traveled outside of our country in the last 21 days? *

Yes

Have you traveled anywhere for leisure or work or been in groups more than 25? *

Yes

If yes to question above please explain!

Are you over the age of 60 with underlying health conditions such as heart disease, lung disease, kidney disease, asthma, diabetes, an auto-immune disease, or cancer? *

Yes

I understand when I get to Stanford Dental, I will wait inside my car and call 636-256-3559 upon my arrival. *

I understand

I do not understand

I understand my temperature must be taken upon arrival (any temp. over 100 degrees will be rescheduled) and I will be asked to wash my hands before being taken directly back to the clinical room. *

I understand

I do not understand

Required

I understand that I must limit, to the best of my ability, those who come with me to my dental appointment. (Our waiting room will be temporarily closed) *

I understand

I do not understand

I understand that if I develop any of the symptoms above before my dental appointment, I will call to reschedule immediately. *

I understand

I do not understand

Please submit below. If you have any questions, don't hesitate to reach out to us at 636-256-3559. If these symptoms change after filling this out please give us a call. We look forward to seeing you!

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