Patient Screening - Online Form

If you are completing this form for someone other than yourself, please answer all questions related to the PATIENT.

Patient Name:

Please indicate if this submission is for PRE-APPOINTMENT or IN-OFFICE PRE-APPOINTMENT
IN-OFFICE

Today's Date

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?Yes
No

Are you/they having shortness of breath or other difficulties breathing?Yes
No

Do you/they have a cough?Yes
No

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?Yes
No

Have you/they experienced recent loss of taste or smell?Yes
No

Are you/they in contact with any confirmed COVID-19 positive patients?Yes
No

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Is your/their age over 60?Yes
No

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?Yes
No

Have you/they traveled in the past 14 days to any regions affected by COVID-19?Yes
No

(as relevant to your location)

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.

Confirmation

I agree that any form of electronic signature, including but not limited to signatures via facsimile, scanning, or electronic mail, may substitute for the original signature and shall have the same legal effect as the original signature.