Algonac Dental COVID-19 Patient Screening Form

Algonac Dental

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)?*

NoYes

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

NoYes

Do you have a dry cough?*

NoYes

Do you have a runny nose?*

NoYes

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

NoYes

Do you have a sore throat?*

NoYes

Are you experiencing chills or repeated shaking with chills?*

NoYes

Do you have unexplained muscle pain?*

NoYes

Do you have a headache?*

NoYes

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

NoYes

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 testedAwaiting results of a testTest results were negativeTest 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?*

NoYes

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.

Thank you for your continued trust in our practice. As with the transmission
of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus,” at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.

Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. “Social Distancing” nationwide has reduced the transmission of the Coronavirus.

Although we have taken measures to provide social distancing in our practice,
due to the nature of the procedures we provide, it is not possible to maintain
social distancing between the patient, dentist, dental staff and
sometimes other patients at all times.

Although exposure is unlikely, do you accept the risk and consent to treatment?*

NoYes

Signature*

Clear