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Patient Screening Form

Are you filing this form out in-office or before your appointment?

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

Are you/they having shortness of breath or other difficulties breathing?

Do you/they have a cough or a sore throat?

Any other flu-like symptoms, such as gastrointestinal upset, nausea, diarrhea, headache or fatigue?

Have you/they experienced recent loss of taste or smell?

Are you/they in contact with any confirmed COVID-19 positive patients? 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?

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (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.
We Are Open And Ready To See You

There is a new normal after we open. Before arriving to your dental appointment, please complete this patient screening form required by law.

Make sure you also visit this link to learn about the changes we have made to keep you safe. Contact the office if you experience COVID-19 symptoms within 14 days after the dental appointment.

para español

Comuníquese con el consultorio si experimenta síntomas de COVID-19 dentro de los 14 días posteriores a la cita dental.

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