COVID-19 Screening Questionnaire

Client Information

Patient's Full Name

Parent/Legal Guardian or Spouse

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Email address

Phone number

Appointment Information

You must complete this COVID-19 screening questionnaire before each visit to our office on the day of your visit. Please confirm today's date and the date of your appointment.

Today's date

Date of your appointment

Symptom History

Have you experienced any of the following symptoms in the past 14 days?

Fever or chills

Yes No

Cough

Yes No

Shortness of breath or difficulty breathing

Yes No

Fatigue

Yes No

Muscle or body aches

Yes No

Headache

Yes No

New loss of taste or smell

Yes No

Sore throat

Yes No

Congestion or runny nose

Yes No

Nausea or vomiting

Yes No

Diarrhea

Yes No

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

Yes No

Contact History

In the past 14 days have you had close contact with anyone who has been diagnosed with COVID-19 or suspected to have COVID-19?

Yes No

In the past 14 days have you had close contact with anyone who has travelled to any other states or any other country?

Yes No

Travel History

In the past 14 days have you visited any other states?

Yes No

If yes, list every state you have visited in the past 14 days

In the past 14 days have you visited any other countries?

Yes No

If yes, list every country you have visited in the past 14 days

Please complete this questionnaire again if any of your answers change before your appointment.

Dental Treatment Consent, Assumption of Risk, and Waiver of Liabilty

I, the patient/legal guardian named above, knowingly and willingly consent to have elective dental treatment completed during the COVID-19 pandemic.

I understand that the COVID-19 virus has a long incubation period during which whomever carries the virus may not show signs or symptoms and may still be highly contagious. It is impossible to determine who has it and who does not given the current limits in viral testing. The virus has shown that it is primarily transmitted through touch and respiratory droplets. The ultra-fine nature of water spray from dental procedures can linger in the air which can transmit the COVID-19 virus.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that by receiving dental treatment, I may be exposed or infected by COVID-19 and that such exposure or infection may result in personal injury, illness, disability, and death. I hereby acknowledge and assume sole responsibility for the foregoing risks, and give my express permission for Dr. Sara Klasinksi and the staff at Kewaskum Family Dentistry, S.C. to proceed with providing my dental treatment.

I hereby release and agree to hold harmless Kewaskum Family Dentistry, S.C., its empolyees, owners, and representatives, from all liability, claims, actions, damages, costs and other expenses relating to my dental treatment and the risks associated with COVID-19.

In addition to the Consent, Assumption of Risk, and Waiver of Liability set forth above, I acknowledge that the disclosures made in this document are true and correct. I acknowledge and understand that Kewaskum Family Dentistry, S.C. and its employees reserve the right to discontinue or delay dental treatment in their sole discretion.

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