COVID Screening Form

Patient's Name*

Age*

Have you or your child had a COUGH, FEVER, RECENT LOSS of TASTE or SMELL, SORE THROAT , or SHORTNESS OF BREATH in the last 48 hours?*

Yes - Please do not enter the buildingNo

Have you or your child TESTED POSITIVE or been DIAGNOSED as having COVID-19, had CONTACT with a person infected with COVID-19 within the last 14 days?*

Yes - Please do not enter the buildingNo

Does your child have a chronic lung condition, heart disease, diabetes, or take an immune suppressive medication?*

YesNo

Has your child had any medical changes, including surgeries?*

YesNo

If so, what?

Is your child taking any medication at this time?*

YesNo

If so, what?

Has your child had radiation and/or chemotherapy within the last year?*

YesNo

Do you have concerns regarding your child's dental health?*

YesNo

If so, what?

Do you consent to diagnostic dental X-rays on your child today, if requested by the Doctor?*

YesNo

I hereby acknowledge and understand that there may be an increased risk that COVID-19 may be transmitted in any place of public accommodation, which includes my dentist’s office. I have been informed by my dentist of their desire to protect their patients, staff, and the community at large.

I agree to notify the dental practice if within 14 days I or my child becomes ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days

Parent/Guardian Signature*

Please Sign with Your Finger/Stylus

Relationship to Patient*

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