Patient Screening Form

Please correct the errors described below.


Exposure Screening

Check for Symptoms

Assess for High Risk Conditions

In-Office Appointment

Exposure Screening

Check for Symptoms

Assess for High Risk Conditions

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

1. Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

2. Malaise - A general feeling of discomfort, illness, or uneasiness whose exact cause are difficult to identify.

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

Examples of High-Risk Medical Conditions

Chronic Lung Disease

  • Asthma
  • COPD
  • Other chronic conditions associated with impaired lung function or that require home O2

Serious Heart Conditions

  • Congestive heart failure

Diabetes with Complications

  • Limb amputation
  • Kidney disease
  • Vision problems
  • Heart disease
  • History of stroke
  • Uncontrolled diabetes

Neurological Conditions that Weaken Ability to Cough

  • Disorders of the brain, spinal cord, peripheral nerve and muscle
  • Cerebral palsy
  • Epilepsy
  • Stroke
  • Intellectual disability
  • Mod-severe developmental delay
  • Muscular dystrophy
  • Spinal cord injury

People with Weakened Immune System

  • Seeing a doctor for cancer
  • Chemotherapy
  • Radiation treatment
  • Organ donation
  • Bone marrow transplant
  • Consuming high doses of oral steroids and /or immunosuppressant


  • Under treatment for kidney disease
  • Receiving dialysis
  • Chronic kidney disease

Cirrhosis of the liver

  • Cirrhosis
  • Chronic hepatitis
  • Under treatment or has liver disease

Extreme Obesity

  • BMI greater than or equal to 40


  • In the last 2-weeks
  • Currently

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