COVID-19 Patient Screening Form

COVID-19 Patient Screening Form
Patient Name:

First Name Last Name
Select Appointment Type *

Pre-Appointment In-Office
Appointment Date

Month Day Year
Date
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? *

Yes No
Are you/they having shortness of breath or other difficulties breathing? *

Yes No
Do you/they have a cough? *

Yes No
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *

Yes No
Have you/they experienced recent loss of taste or smell? *

Yes No
Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. *

Yes No
Is your/their age over 60? *

Yes No
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? *

Yes No
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) *

Yes No
Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

• For testing, see the list of State and Territorial Health Department Websites for your specific area’s information.
Signature *

Clear
Your Name *

First Name Last Name
Date *

Month Day Year
Date
Should be Empty: