COVID-19 Prescreening Form
Please complete this form prior to you visit. In order to maintain social distancing, please limit the waiting room to two people, wait in our outdoor waiting area, or wait in your car and we will call or text you when we are ready for your appointment.
Masks
All of our treatment rooms are self contained. However, when not in a treatment room, please wear a mask when visiting the office. If you do not have one, a mask will be provided to you.
Dental Staff Considerations
Our staff is screened twice daily, as recommended by the CDC, for any symptoms of COVID-19. No member of the staff has tested positive or knowingly been exposed to anyone with COVID-19. Our staff will be wearing an N-95 equivalent mask during all procedures.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Primary Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Patient Screening
Have you been partially or fully vaccinated for COVID-19?
Yes
No
Have you tested positive for COVID-19?
Yes
No
If YES, when was your positive COVID-19 test result:
-
Month
-
Day
Year
Date
Have you been tested for COVID-19 and are awaiting results?
Yes
No
Do you have any of the following respiratory symptoms? Fever, Sore Throat, Cough, Shortness of Breath?
*
Yes
No
Have you recently lost your sense of smell or taste?
Yes
No
Do you have any GI symptoms? Diarrhea? Nausea?
Yes
No
Even if you don't currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
*
Yes
No
Have you been in contact with anyone who has tested positive for COVID-19 in the last 14 days?
Yes
No
Have you traveled outside the United States by air or cruise ship in the past 14 days?
Yes
No
I will make the office aware if I become symptomatic and test positive for COVID-19 within 14 days of treatment.
Yes
No
Date
*
-
Month
-
Day
Year
Date
Signature: By signing your name in the box below, you acknowledge that your answers you provided are true and accurate to the best of your knowledge. You also understand the elevated risk of exposure to COVID-19 and consent to dental treatment completed during the COVID-19 pandemic:
*
Submit Survey
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