silverspringdentalarts - COVID19 Intake

Respiratory intake form for Silver Spring Dental Arts
For all of our safety, please fill this out prior to your dental appointment (until further notice). Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the severe COVID-19 signs.
Name*

First NameLast Name

In the past 14 days, I have experienced... *

	Yes	No
Are you having shortness of breath or other difficulties breathing?
Do you have a cough?
Any other flu-like symptoms (eg: GI upset, headache, fatique?) *In children this includes runny rose, rash and/or "COVID Toes"
Have you experienced recent loss of taste or smell?
Are you in contact with any people who have been sick with above sxs? *If you are well but a member of your household is sick, consider postponing treatment.
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? *Lupus, Rhumatoid Arthritis, Lyme, Cancer, Transplant, AIDS, etc.
Have you traveled in the past 14 days to regions affected by COVID-19? *Relevant to our location: New York, New Jersey

I agree*

that I am providing accurate health information. I also understand that SSDA has taken many steps to lower the risk of coronavirus transmission during the current pandemic. I understand that SSDA relies on ME to TRUTHFULLY report ANY and ALL potential risk factors honestly and openly. Based on the above, I agree to treatment at SSDA.
Signature*

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