Kleypas DDS - COVID 19 Screening Form

1

Patient Name* This field is required.

First Name

Last Name

2

Have you tested positive for COVID-19?* This field is required.

YESNO

3

Have you been tested for COVID-19 and are awaiting results?* This field is required.

YESNO

4

Do you have any of the following respiratory symptoms: fever, sore throat, cough, shortness of breath?* This field is required.

YESNO

5

Have you recently lost your sense of smell or taste?* This field is required.

YESNO

6

Do you have any GI symptoms? Diarrhea? Nausea?* This field is required.

YESNO

7

Even if you don't currently have these symptoms, have you experienced any of these symptoms in the last 14 days?* This field is required.

YESNO

8

Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?* This field is required.

YESNO

9

Have you traveled outside the United States by air or cruise ship in the past 14 days?* This field is required.

YESNO

10

Have you traveled within the United States by air, bus or train within the past 14 days?* This field is required.

YESNO

11

Do you/the patient have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?* This field is required.

YESNO

12

If you experience any COVID-19 symptoms within 14 days of visiting our office for your dental appointment, please contact our office immediately.

13

If you answered "Yes" to any of these questions. Please contact our office immediately.

14

Patient or Guarantor's Signature* This field is required.Use your mouse or finger to draw your e-signature.

Clear

15

Today's Date* This field is required.

Date