DENTAL PRE-SCREENING FORM
Please confirm if you are presenting any of the following symptoms of COVID-19:
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Cough
Sore throat
Fever >37.5
Flu-like symptoms
None
Other
What kind of appointment are you looking for? Are you experiencing any pain? If any infection, swelling, bleeding or trauma, please explain the situation:
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Are you experiencing pain? If so, how bad is the pain? How do you rate it on a scale 1 (mild) - 10 (severe):
1
2
3
4
5
6
7
8
9
10
No pain
Please upload a PHOTO/X-RAY of the situation, if possible. By having pictures, we can facilitate your appointment booking process:
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Current dentist's name and number:
Current physician's name and number:
Please list all prescription and over the counter medications that you are taking including the name, dosage, purpose and time of the day taken. Please say "NO MEDICATION" if not.
*
Are you allergic to or had a reaction to the following:
Local anesthetics
Codeine or other narcotics
Latex
Penicillin or any antibiotics
Sulfa drugs
Metals
Hay fever
Iodine
Barbiturates
Other
Full Name
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First Name
Last Name
Phone
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Area Code
Phone Number
E-mail
Signature
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