Valley Family Dental Group

1

Full Name* This field is required.

First Name

Last Name

2

Appointment Date* This field is required.

Date

3

Do you have fever or have you felt hot or feverish recently (14 - 21 days)?* This field is required.

YESNO

4

Are you having shortness of breath or other difficulties breathing?* This field is required.

YESNO

5

Do you have a cough?* This field is required.

YESNO

6

Have you experienced recent loss of taste or smell?* This field is required.

YESNO

7

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?* This field is required.

YESNO

8

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

YESNO

9

Are you in contact with any confirmed COVID-19 positive patients?* This field is required.Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

YESNO

10

Is your age over 60?* This field is required.

YESNO

11

Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)* This field is required.

YESNO

12

Signature* This field is required.

13

formreceiver

14

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