JFK Dental Covid-19 Patient Screening

Just For Kids Dental Waxahachie

Armin Aliefendic, DDS & Associates
Covid-19 Patient Screening

In response to the recent Coronavirus (COVID -19) outbreak and the raised pandemic alert status by the World Health Organization (WHO), Just for Kids Dental Waxahachie is taking precautions to lessen the spread of the virus. All patients must have a screening form completed.
Has the patient or anyone in the family (household) tested positive for COVID-19? *

Yes No
Has the patient or anyone in the family (household) been tested for COVID-19 and is awaiting results? *

Yes No
Does the patient or anyone in the family (household) have any of the following respiratory symptoms? Fever, Sore Throat, Cough, Shortness of Breath? *

Yes No
Has the patient or anyone in the family (household) recently lost your sense of smell or taste? *

Yes No
Does the patient or anyone in the family (household) have any GI symptoms? Diarrhea? Nausea? *

Yes No
Even if you don’t currently have any of the above symptoms, has the patient or anyone in the family (household) experienced any of these symptoms in the last 14 days? *

Yes No
Has the patient or anyone in the family (household) been in contact with someone who has tested positive for COVID-19 in the last 14 days? *

Yes No
Has the patient or anyone in the family (household) traveled outside the United States by air or cruise ship in the past 14 days? *

Yes No
Has the patient or anyone in the family (household) traveled within the United States by air, bus or train within the past 14 days? *

Yes No
What does this mean?

If ‘Yes’ to any of the above questions, a team member of Just for Kids Dental will reschedule your child(ren)’s dental appointment. Please contact your doctor for further advice. If you do not meet the criteria above, please sign below indicating that you have been provided with this information. Thank you for your cooperation.
I HAVE REVIEWED THE ABOVE CRITERIA. MY CHILD(REN) AND I DO NOT HAVE SYMPTOMS AS DESCRIBED.
Patient Name (your child's name) *

First Name Last Name
Patient Name (if multiple children)

First Name Last Name
Patient Name (if multiple children)

First Name Last Name
Patient Name (if multiple children)

First Name Last Name
Legal Guardian Name *

First Name Last Name
Date *

Month Day Year
Date
Signature of Legal Guardian *

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Just For Kids Dental Waxahachie

Covid-19 Patient Screening

What does this mean?

I HAVE REVIEWED THE ABOVE CRITERIA. MY CHILD(REN) AND I DO NOT HAVE SYMPTOMS AS DESCRIBED.