Form

Dear Patient:

You are scheduled to come to our office for dental services that will be done during the COVID-19 pandemic. Please be advised of the following:

While our office complies with State Health Department and CDC to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we will ask you a number of "screening" questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.

In the past 14 to 21 days have you had a fever? *

Yes No

Are you having shortness of breath or difficulties breathing? *

Yes No

Do you have you had a cough? *

Yes No

Have you experienced recent loss of taste or smell? *

Yes No

Have you had any flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *

Yes No

Have you been in contact with a confirmed COVID-19 positive patient in the past 14 days? *

Yes No

Have you traveled in the past 14 days to any regions outside the United States? *

Yes No

Are you currently awaiting test results for the COVID-19 test? *

Yes No

If you answered yes to the question above, did you test positive for COVID-19?

Yes No Not Applicable

Patient Name: *

First & Last Name (or responsible party)

Date of Appointment: *

Today's Date: *

COVID-19 Health Screening Questionnaire