Coronavirus Self Assessment Form

Coronavirus Self Assessment Form

For the health and safety of our community, we require each patient to have this form filled prior to their appointment. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
Patient’s Name *

First Name Last Name
Have you or your immediate family tested positive for COVID-19? *

Yes No Yes but I have tested Negative since Other
Have you traveled to an area that has a high rate of COVID-19? Example: Florida, Texas, Arizona, California *

Yes No
Name of the area(s) visited and dates
Please understand that if you have had recent travel We ask that you self quarantine for 14 days prior to your appointment
Have you been in contact with people being infected, suspected or diagnosed with COVID-19? *

Yes No
Your relationship with the people and your last contact date with them

Please state whether you've experienced/are experiencing the following *

Yes

Fever

Cough

Shortness of Breath

Persistent Pain in the Chest

Loss of Taste or Smell

Even after following protocols set by the American Dental Association and our state’s dental association, it is still possible to contract COVID-19 while at a dental office. We are following all guidelines to minimize the risk of transmission. *

Yes

I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. I understand that the COVID-19 virus has a long incubation period during which carriers of this virus may not show symptoms and may still be highly contagious.

I understand that – due to the frequency of visits of other dental patients, the characteristics of the COVID-19 virus, and the characteristics of dental procedures – I have an elevated risk of contracting the COVID-19 virus simply by being in a dental office.

I acknowledge that the information I've given is accurate and complete.
Date *

Month Day Year
Date
Signature *

Clear
Should be Empty: