COVID-19 SCREENING FORM
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Country Code
Phone Number
Body Temperature
Patient Screening Questions
1. Do you have any flu-like symptoms, such as fever, cough, colds, sore throat, shortness of breath, nausea, body malaise, diarrhea, loss of taste, or headache?
Yes
No
2. Are you in contact with any confirmed COVID-19 positive patients?
Yes
No
3. Have you been in close contact with a COVID-19 person under investigation (PUM)?
Yes
No
4. Have you travelled to any areas with known COVID-19 cases in the past 14 days?
Yes
No
5. Is there anything else we should know before treating you?
Yes
No
Patient's Consent
I give my full consent to have my dental treatment during this COVID-19 Pandemic
The virus can be transmitted by contact through surfaces and that it can stay in the air for 5-72hrs. I am aware that it is impossible to identify who is probable, suspect or COVID-19 Positive. Because of this, treatments are limited to urgent and emergent care only to protect me, other patients, and the dental staff.
I recognize that the clinic is adhering to the most strict infection control protocols for my protection and I agree to cover the fees that this entails.
I fully understand that because of the nature of the virus, going to the clinic, having dental treatments, and simply staying in the dental office puts me at risk and that I have a higher chance of contracting the virus. Should I contract the virus, I hereby agree that I shall not hold the dental office and its staff responsible.
In accordance with the government rules, I give my full consent to reveal my identity for possible contact tracing for the interest and safety of the community.
Acknowledgement
I understand that withholding vital information and failing to cooperate is PUNISHABLE BY LAW under RA 9271 “Quarantine Act of 2004” and RA 11332 “Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern Act”. I hereby declare that the above statements are true, accurate and complete
Signature
Submit
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