COVID-19 ACKNOWLEDGEMENT AND SCREENING

COVID-19 ACKNOWLEDGEMENT AND SCREENING
Patient Name(s)*
First and last name of each person attending an appointment
Parent/Guardian Name (for patients under the age of 18)

First NameLast Name
Todays Date*

MonthDayYear
Date
YesNo
YesNo
Do you have any of the following symptoms?
- Fever and/or chills.
- New onset of cough or worsening chronic cough.
- Shortness of breath.
- Decrease or loss in taste or smell.
- If adult +18 years of age; unexplained fatigue/lethargy/malaise/muscle aches.
- If child -18; nausea/vomiting, diarrhea
YesNo
I verify the information I have provided on this form is true and correct. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. *

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SIGNATURE OF PATIENT, PARENT OR GUARDIAN
Should be Empty: