Pre-Appointment Questionnaire

Type a question
Are you vaccinated?

YesNo
Date of Last Vaccine

MonthDayYear
Pre-Appointment Questionnaire

COVID-19 Pandemic Dental Treatment Consent Form
I verify that I have not traveled outside the United States during the past 14 days to
countries that have been affected by COVID-19.
Date

MonthDayYear
I verify that I have not traveled within the United States by commercial airline, bus, or
train within the past 14 days.
I knowingly and willingly consent to having emergency and/or elective dental treatment completed during the COVID-19 pandemic.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. Given the current limits in virus testing, it is impossible to determine who has it and who does not have COVID-19.
Patient's Name
Dental procedures create water spray (aerosols), which is one way the disease can be spread. The ultra-fine nature of the spray can linger in the air for several minutes to hours, which can transmit the COVID-19 virus.
Full Name

First NameLast Name
I understand that due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office.
Email
example@example.com
I confirm I am seeking treatment for a condition that meets these criteria.
Phone Number

Area CodePhone Number
I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:
● Fever ● Shortness of breath ● Dry cough ● Runny nose ● Sore throat
Do you have a fever, or have you felt feverish recently?

YesNo
Do you have a cough?

YesNo
I understand that air travel significantly increases the risk of contracting and transmitting the COVID-19 virus. The CDC recommends social distancing of at least 6 feet for a period of 14 days around anyone who has traveled by air, and this distance is not possible with dentistry.
Are you having shortness of breath or any difficulty breathing?

YesNo
Do you have chills or repeated shaking with chills?

YesNo
Do you have any muscle pain?

YesNo
Do you have any recent onset of headache or sore throat?

YesNo
Do you have any other flu-like symptoms?

YesNo
Do you have any recent loss of taste or smell?

YesNo
Have you experienced any recent GI upset or diarrhea?

YesNo
Are you in contact with anyone who has been confirmed to be COVID-19 positive?

YesNo
Have you traveled in the past 14 days to any regions affected by COVID-19?

YesNo
Are you over the age of 65?

YesNo
Do you have:

Heart diseaseLung diseaseKidney diseaseDiabetesAutoimmune disordersNone of the above
Should be Empty: