COVID-19 Patient Prescreening Form
Please fill out the form 48 hours prior to your appointment.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Do you have a fever or above-normal temperature (>100.4°F)?
*
Yes
No
Are you experiencing shortness of breath or having trouble breathing?
*
Yes
No
Do you have a dry cough?
*
Yes
No
Do you have a runny nose?
*
Yes
No
Have you recently lost or had a reduction in your sense of smell or taste
*
Yes
No
Do you have a sore throat?
*
Yes
No
Are you experiencing chills or repeated shaking with chills?
*
Yes
No
Do you have unexplained muscle pain?
*
Yes
No
Do you have a headache?
*
Yes
No
Even if you don't currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
*
Yes
No
Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?
*
Yes
No
Have you been tested for COVID-19 in the last 14 days?
*
Yes
No
If you have been test for COVID-19, what is result of the test?
Positive
Negative
Still waiting on results
Have you or any of your household members traveled more than 100 miles from your home in the last 14 days?
*
Yes
No
Signature: 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.
*
Clear
Office email
example@example.com
Submit
Should be Empty: