COVID-19 Patient Screening Form

Patient's Name

Age:

Today's Date

PRE-Appointment

1. Do you have a fever or have you felt feverish recently?

Yes No

2. Are you having shortness of breath, other difficulties breathing or a cough?

Yes No

3. Do you have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes No

4. Have you experienced recent loss of taste or smell?

Yes No

5. Have you been tested for C0VID-19 or had an antibody test?

Yes No

6. Are you in contact with any confirmed C0VID-19 positive patients? Patients who are well but who have a sick family member at home with CO V/0-19 should consider postponing elective treatment.

Yes No

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

Yes No

8. Have you traveled by air, bus, or train within the past 14 days?

Yes No

If so, where?

9. Have you been fully vaccinated?

Yes No

If so, what was the date of your last vaccine?

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 list of State of Territorial Health Department Website for your specific area's information.

COVID-19 Consent Form

Responding to the public health hazard posed by Coronavirus disease 2019 ("COVID-19"), effective 5:00 p.m. on Friday, March 27, 2020, Governor Philip D. Murphy ordered and directed the suspension of all surgeries or invasive procedures performed on adults that can be delayed without undue risk to the current or future health of the patient as determined by the patient's treating physician or dentist.

I acknowledge and understand that there is an increased risk that COVID-19 can be transmitted in any place of public accommodation, including a dental office, and I have been informed that my dentist desires to protect the safety of the dental office and the patients, staff and other individuals who come upon the premises

Accordingly, as a precondition to rendering treatment, I have confirmed that I have no symptoms commonly associated with COVID-19, including fever, shortness of breath, dry cough, running nose or sore throat and that I have not, within the past 14 days, traveled by airplane, been in close proximity (less than 6 feet proximity) at a gathering of 10 or more persons, or had close contact with a person who has confirmed positive or suspected to be positive for COVID-19.

I consent to the performance of the treatment proposed by my dentist.

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:

Short text

Your information will be encrypted.