benyountdds.com - Covid Patient Screening Form

Patient/Parent/Guardian Names:

Are you fully vaccinated for COVID-19?

Yes No

Do you have a fever a above normal temperature?(>100.0 F) Take temperature at appointment

Yes No

Are you experiencing more than one of the following symptoms: shortness of the breath, dry cough, sore throat, unexplained muscle pain, headache or nausea, new loss of taste or smell?

Yes No

Even if you don't currently have any of the above symptoms, have you experienced more than one of these symptoms in last 14 days?

Yes No

Have you been advised to quarantine due to close contact with someone diagnosed with COVID-19?

Yes No

Have you been Tested for COVID-19 in the last 14 days?

Yes No

What is the result of testing?

Negative Unsure Postive

Schedule appointment after results are known

Have you traveled out of state or out of country in the last 14 days?

Yes No

Have you received the first Covid Booster vaccine?

Yes No

Have you received the second Covid booster vaccine?

Yes No

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 that the dental practice has a legal and ehtical obligation to inform me if a staff person I had close contact with tested positive for COVID-19 within 2 days.

Acepto dar aviso o lo clínica dental si dentro de dos días presento síntomas de COVID-19 o tengo un resultado positivo de COVID-19. Entiendo que la clínico dental tiene la obligación legal y ético de informarme si un miembro del personal con el que tuve contacto ho tenido un resultado positivo de COVID-19 dentro de dos días.

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Covid Patient Screening Form

Screening Questions