If you are completing this form for someone other than yourself, please answer all questions related to the PATIENT.
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
(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.
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.