COVID-19 Screening/ Disclosure

Please fill out this screening form within 24 hours of your scheduled dental appointment.

This patient disclosure form seeks information from you that we must consider before making decisions in the circumstance of the COVID-19 virus.

I knowingly & willingly consent to have dental treatment completed during the COVID-19 Pandemic. I understand that The World Health Organization has classified Covid-19 as a pandemic. The COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. It is impossible to determine who has it and who does not; given the current limits in virus testing. Dental procedures produce aerosols allowing the virus to be transmitted via the air. Standard precautions reduce risk as much as possible, but you are unable to wear a protective mask during dental treatment and this is how the virus could be spread.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment radiation, chemotherapy and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus. If you have been exposed or could potentially be a carrier, please stay home and call us to reschedule your appointment.

Do you have a temperature 100.4 or greater?
YesNo

Have you experienced shortness of breath or had trouble breathing?
YesNo

Do you have a dry cough?
YesNo

Have you recently had a loss or reduction in taste or smell?
YesNo

Do you have a sore throat?
YesNo

Have you been in contact with someone who has tested positive for COVID-19?
YesNo

Have you tested positive for COVID-19?
YesNo

Have you been tested for COVID-19 and are awaiting results?
YesNo

Have you traveled outside the United States by air or cruise ship in the past 14 days?
YesNo

Have you traveled within the United States by air, bus or train within the past 14 days?
YesNo

I understand that I will contact the office (and my Primary Care Physician) if I develop any COVID-19 symptoms within the next 14 days.

Please record your temperature at home within 24 hours of your appointment and record below.

Date recorded:

I confirm that I have read the notice above and understand and accept the increased risk of contracting Covid-19 with having dental treatment or being in this dental office. I fully understand that I can contract the Covid-19 virus from outside the dental office in circumstances unrelated to my dental visit. I acknowledge that the answers I have provided above are true and accurate.

Signature of Patient/Guardian