COVID Screening

Responding to the public health hazard posed by Coronavirus disease 2019 (“COVID-19”), effective 5:00 p.m. on Friday, March 27, 2020, the governor ordered and directed the suspension of all surgeries or invasive procedures performed on adults that can be delayed without undue risk to the current or future health of the patient as determined by the patient’s treating physician or dentist.

I acknowledge and understand that there is an increased risk that COVID-19 can be transmitted in any place of public accommodation, including a dental office, and I have been informed that my dentist desires to protect the safety of the dental office and the patients, staff and other individuals who come upon the premises

Accordingly, as a precondition to rendering treatment, I have confirmed that I have no symptoms commonly associated with COVID-19, including fever, shortness of breath, dry cough, running nose or sore throat and that I have not, within the past 14 days, travelled by airplane, been in close proximity (less than 6 feet proximity) at a gathering of 10 or more persons, or had close contact with a person who has confirmed positive or suspected to be positive for COVID-19.

I consent to the performance of the treatment proposed by my dentist.

Name:

Signature:

Date:

Date

Patient Name

First NameLast Name

Date

Type a question

	Pre-Appointment YES	Pre-Appointment NO	In-Office YES	In-Office NO
Do you have a fever or have you felt hot or feverish recently (within 14-21 days)?
Are you having shortness of breath of other difficulties breathing?
Do you have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you experienced recent loss of taste or smell?
Are you 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.
Is your age over 60?
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you traveled in the past 14 days to any regions affected by COVID-19?

Dates for any pre-appointment YES responses:

Patient Request for Treatment, Representations and Consent

Patient Screening Form