COVID-19 Screening and Dental Treatment Consent Form

COVID-19 Screening and Dental Treatment Consent Form
Name*

First NameLast Name
Temp
Date*

MonthDayYear
Date
IN THE LAST TWO WEEKS
1. Have you been around anyone who has symptoms of COVID-19 or has tested positive for COVID-19?*

YesNo
2. Have you recently traveled anywhere that the CD would recommend you quarantine or self-isolate?*

YesNo
3. Have you experienced any of the following symptoms? (Please circle all that apply)

a. Feverb. Coughingc. Flu Symptomsd. Body achese. Sore Throat
4. IF YES TO ANY OF #3, PLEASE EXPLAIN.
Signature*

Clear
Patients Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty: