New Patient Information Form

Please correct the errors described below.

New Patient Information

Patient's Name

Date of Birth

Address

City

State

Zip

Home Phone

Cell Phone

Email address

Patient SSN#

Employed By

Business Phone

Business Address

Dental Insurance Plan

Dental Claim Address

Subscriber Name

Subscriber DOB

Group Number

Subscriber ID

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Patient Screening Form

Do you have a fever or have felt hot feverish recently (14-21 days)?

Yes No

Are you having shortness of breath or other difficulties breathing?

Yes No

Do you have a cough?

Yes No

Any other flu-like symptoms, such gastrointestinal upset, headache, or fatigue?

Yes No

Have you experienced recent loss of taste or smell?

Yes No

Are you in contact with any COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Yes No

Is your age over 60?

Yes No

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Yes No

Have you traveled in the past 14 days to any regions affected by COVID-19? (As Relevant to Your Location)

Yes No

Positive Responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing, see the Massachusetts Department of Public Health website for testing information and testing locations.

Your information will be encrypted.

Electronic signature

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