COVID-19 screening form.
Patient Disclosure
This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19 virus.A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.
Do you have a fever or temperature above normal?
*
Yes
No
Have you experienced shortness of breath or had trouble breathing?
*
Yes
No
Do you have a dry cough?
*
Yes
No
Do you have a runny nose?
*
Yes
No
Have you recently lost or had a reduction in your sense of smell or taste?
*
Yes
No
Do you have a sore throat?
*
Yes
No
Have you been in contact with anyone in the last 14 days who is experiencing these symptoms?
*
Yes
No
Have you been tested for COVID-19 in the past 14 days?
*
Yes
No
If so, date of test
-
Month
-
Day
Year
Date
and have you tested
Positive
Negative
Awaiting Results
Have you travelled outside the United States by air or cruise ship in the past 14 days?
*
Yes
No
Have you traveled within the United States by air, bus or train within the past 14 days?
*
Yes
No
Have you been vaccinated for COVID-19?
*
Yes
No
If you received the Johnson & Johnson / Janssen vaccine: Date of single dose vaccination
-
Month
-
Day
Year
Date
If you received the Moderna or Pfizer-BioNTech: Date of 1st vaccination. Date of the second vaccination.
-
Month
-
Day
Year
Date
If you received a booster vaccine: Date of vaccination.
-
Month
-
Day
Year
Date
I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system. By signing this document, I acknowledge that the answers I have provided above are true and accurate. Signature of the patient (Parent or Guardian if Minor)
*
COVID-19 Pandemic Dental Treatment Notice and Acknowledgement of Risk Form
The World Health Organization has characterized the COVID-19 virus, also known as “Coronavirus,” as a pandemic. Our practice wants to ensure you are aware of the risks of exposure to COVID-19 associated with receiving treatment during this pandemic.COVID-19 is highly contagious and has a long incubation period. You or your healthcare providers may have the virus, not show symptoms and yet still be highly contagious. COVID-19 can result in a life-threatening respiratory disease in some patients. You may be exposed to COVID-19 at any time or in any place. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.Dental procedures can create fine water spray or “aerosols” which may remain in the air for several minutes to hours. These aerosols may contain the COVID-19 virus and may create a risk of COVID-19 exposure. You cannot wear a protective mask over your mouth to reduce exposure during treatment as your healthcare providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.To provide a safe environment for our patients and staff, this practice follows the applicable state and federal regulations and protocols for infection control, universal personal protection, and disinfection. However, due to the nature of the procedures we provide, it may not be possible to maintain social distancing between patients, doctors, and staff at all times.
Patient Acknowledgement
I acknowledge that I have read the Notice above and that I understand and accept that there is an increased risk of COVID-19 exposure with treatment during the pandemic. I understand and accept the increased risk of COVID-19 exposure with treatment at this office. I also acknowledge that I could, or may have, been exposed to COVID-19 from outside this office and unrelated to my visit here. Signature of Patient (Parent or Guardian if Minor)
*
Demographic Information
Patient Information
Prefix
*
Mr.
Mrs.
Ms.
Dr.
Sex
*
Male
Female
Full Name
*
First Name
Last Name
Birth Date
*
-
Day
-
Month
Year
Date
Age
*
Social Security
*
Email
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Home Number
-
Area Code
Phone Number
Have you ever been a patient of our practice?
Yes
No
Has a family member ever been a patient of our practice?
Yes
No
Who were you referred by?
First Name
Last Name
Dentist Name
First Name
Last Name
Orthodontist Name
First Name
Last Name
Medical Doctor Name
First Name
Last Name
Preferred Pharmacy
First Name
Last Name
Pharmacy Phone
-
Area Code
Phone Number
Section 2
Driver's License Number
Nearest relative not living with you
First Name
Last Name
Relative Phone Number
-
Area Code
Phone Number
Employer / Business Name
Business Phone
-
Area Code
Phone Number
Personal Payment Type
Cash
Check
Credit Card
In Case Of Emergency
Contact
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relation to the patient
Who will be responsible for your account?
Who will be responsible for your account?
*
Self
Father
Mother
Spouse
Other
Name
First Name
Last Name
Social Security
Age
*
Birth Date
*
-
Month
-
Day
Year
Date
Responsible Party's Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Driver's License
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Employer's Phone
-
Area Code
Phone Number
Spouse or other guarantor information (if different from above)
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relation to the patient
Birth date
-
Month
-
Day
Year
Date
Social Security
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Employer's Phone
-
Area Code
Phone Number
Submit
Should be Empty: