Patient Screening Form

Please Select the Correct Choice *

	Before Appointment: Yes	Before Appointment: No	In-office: Yes	In-office: No
Have you tested positive for COVID-19 or are you awaiting results for a COVID-19 test?
Do you have any of the following: Cold or flu-like symptoms Fever, Cough, Sore throat, Headache, Fatigue, Abdominal pain or Diarrhea
Are you having shortness of breath or other difficulties breathing?
Have you experienced recent loss of taste or smell?
Even if you do not currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
Are you, or have you in the last 14 days, in contact with any confirmed COVID-19 positive patients?
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Are you 70 years of age or older, experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

If there is a positive response to any of these, we would recommend discussing with the dentist and team before proceeding with any elective dental treatment.

1. You MUST wear a mask
2. You MUST bring your own pen to sign any documents
3. You MUST call when you arrive, BEFORE entering the office.
Patient/Parent/Guardian Signature *

Clear
Patient Name *

First Name Last Name
Parent/Guardian Name (if applicable)

First Name Last Name
Date*

MonthDay Year
Date
Should be Empty: