BALA INSTITUTE OF ORAL SURGERY COVID-19 PATIENT QUESTIONNAIRE

BALA INSTITUTE OF ORAL SURGERY

COVID-19 PATIENT QUESTIONNAIRE
15 N. PRESIDENTIAL BLVD, SUITE 301 s BALA CYNWYD, PA 19004
(610) 667-6161 s WWW.BALASURGERY.COM

In the continually evolving COVID-19 crisis, we are complying with all protocols to ensure the health and safety of our patients and staff, following the CDC, ADA and PA Department of Health recommendations. All patients are required to follow specific guidelines. Please complete the following form NO EARLIER THAN 48 HOURS PRIOR to your scheduled appointment. Thank you for your cooperation and understanding.
Name (MUST PUT FULL NAME)*

First NameLast Name
Cell #:*
(xxx) xxx-xxxx
Today's Date:*

MonthDayYear
Date
Appointment Date:*

MonthDayYear
Date
Have you been vaccinated?*

YesNo
If yes, when?
If you are vaccinated, we encourage you to upload a copy of your card for your file. Would you like to submit a copy of your card? If you provided us with a copy from a previous visit, you do not need to submit another copy.*

Yes, I will upload itYes, I will text it (610-667-6161)Yes, I will bring it with meI previously provided itNo
Please upload your vaccination card here. If you are unable to upload it, you may take a photo of it and text it to 610-667-6161. Please note, if you choose to text the card and we do not receive it before your appointment, we will require you to go back and answer the questions.

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Regardless of vaccination status, everyone is required to complete the following questions.

WITHIN THE PAST 14 DAYS:
1. Have you had a fever or do you currently have a fever?*

YESNO
2. Have you experienced a recent onset of respiratory problems such as a cough, difficulty breathing or chest pains?*

YESNO
3. Have you come in contact with a patient with confirmed COVID-19 infection?*

YESNO
4. Is there at least one person experiencing fever or respiratory problems having close contact with you?*

YESNO
5. Have you had a recent sudden loss of smell and/or taste?*

YESNO
6. Have you tested positive for COVID-19?*

YESNO
If yes, please provide date of test.
7. Has ANYONE in your household been tested for COVID-19 and awaiting results?*

YESNO
If yes, please provide date of test.
If you answered yes to any of the above questions, please elaborate:
PATIENT GUIDELINES
- If you are having sedation, after checking in, your driver must stay in their car and reachable via their cell phone for our staff.
- If you do not need a driver, you are not having sedation or you are not a minor, please do not bring additional people with you.
- Only patients will be allowed to enter the office (unless the patient is a minor – then one parent/guardian will be permitted in). Our waiting room is closed.No children will be allowed in the office. Please make necessary arrangements for child care.
- All patients will have their temperature taken upon entering our office via touch-free infrared thermometers.
- If you enter our office with any type of cough, you will be asked to leave and call us to reschedule your appointment.
By signing below, I understand the above guidelines and have answered the questions honestly and to the best of my knowledge.
Patient Signature*

PLEASE DO NOT COPY AND PASTE SIGNATURE, IT WILL NOT SHOW UP. Clear
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