Heights Orthodontics COVID-19 Patient Screening Form

Heights Orthodontics

COVID-19 Patient Screening Form

Today's Date

Date

Patient Name *

First Name Last Name

Parent/Guardian Name (if applicable)

First Name Last Name

If you answer “Yes” to either question on shortness of breath or coughing, or if you answer “Yes" to any combination of two other symptoms and the patient does not need emergency care, consider rescheduling until symptoms resolve or until you can provide proof you are not infectious for COVID-19. We are happy to provide additional information regarding symptoms.

Do you have a fever or above-normal temperature (>100.4° F)? *

No Yes

Are you experiencing shortness of breath or having trouble breathing? *

No Yes

Do you have a dry cough? *

No Yes

Do you have a runny nose? *

No Yes

Have you recently lost or had a reduction in your sense of smell or taste? *

No Yes

Do you have a sore throat? *

No Yes

Are you experiencing chills or repeated shaking with chills? *

No Yes

Do you have unexplained muscle pain? *

No Yes

Do you have a headache? *

No Yes

Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days? *

No Yes

If the answer is “Yes” and you do not need emergency care, do not schedule an appointment unless it has been more than 7 days since symptoms first appeared and 3 consecutive days without a fever (use of fever-reducing medication to treat fever does not count toward these days).

Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days? *

No

If you have been tested for COVID-19 what is the result?

Have not been tested Awaiting results of a test Test results were negative Test results were positive

If positive, we will reschedule your appointment until you have been cleared to return by a physician with proper verification. If you are still waiting on the results, please reschedule your appointment until after the results are known.

Have you traveled more than 100 miles from your home in the last 14 days? *

No Yes

If yes, was the area a hot zone for COVID-19 cases? Did you follow physical distancing precautions and wear a mask while in public? Please use professional judgement when determining whether to proceed with the appointment.

Patient signature required at appointment:

I agree to notify the dental practice if within 14 days I become 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.

Signature *

Clear