COVID Form &#8211; Stowers Pediatric Dentists

COVID Form

To be completed within 24 hours of the patient's scheduled appointment.
Patient First Name (required)*
Patient Last Name(required)*
Phone Number*
Your Email (required)
Date of Birth (required)
Have you/ they had a fever within 48 hours?

YesNo
Are you/they having shortness of breath or other difficulties breathing?

YesNo
Do you/they have a cough?

YesNo
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

YesNo
Have you/they experienced recent loss of taste or smell?

YesNo
Are you/they in contact with any confirmed COVID-19 positive patients within 5 days?Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

YesNo
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

YesNo
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

YesNo
Parent/ Guardian Signature
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.
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