Instructions for use: Use one form for each patient appointment. Ask the patient these questions at the time appointment is made or with appointment reminder, and again no more than two days before the appointment.
Note:An individual is considered fully vaccinated if it has been more than 2 weeks since they received the last shot of a 2-dose vaccine (for example, Moderna or Pfizer) or a single dose vaccine (J&J). If the answer is yes, screen for symptoms only and not for close contact, COVID-19 testing or travel. Observational screening, instead of questioning patient about symptoms or having patient complete a form, should be noted in the patient chart.
Note:If patient answers “yes,” note the symptoms reported and seek additional information from the patient about possible cause. If patient does not need emergency care, consider not scheduling or seeing the patient until symptoms resolve.
Note:If “yes” and patient does not need emergency care, do not see patient unless it has been more than 10 days since symptoms first appeared and 24 hours of no fever without use of fever-reducing medication.
Note:If yes, ask when the quarantine period ends and set appointment time after that date.
If yes, what is the result of the testing?No Unsure Positive If negative, proceed to next question. If still waiting on results, schedule appointment after results are knownNote:If positive, determine if patient needs emergency care. If not an emergency, schedule patient to be seen when it has been more than 10 days (20 days if patient illness was severe) since symptoms first appeared and 24 hours of no fever without use of fever reducing medication.
Note:Fully vaccinated individuals need not quarantine, according to the CDC. Know your county’s health officer orders with regard to nonessential travel by individuals not vaccinated for COVID-19. The county orders will have quarantine recommendations.
Patient signature required at appointment: I agree to notify the dental practice if within 2 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 close contact with tested positive for COVID-19 within 2 days. Acepto dar aviso a la clínica dental si dentro de dos días presento síntomas de COVID-19 o tengo un resultado positivo de COVID-19. Entiendo que la clínica dental tiene la obligación legal y ética de informarme si un miembro del personal con el que tuve contacto ha tenido un resultado positivo de COVID-19 dentro de dos días.Signature Signature