COVID-19 UPDATED PATIENT QUESTIONNAIRE

We have taken precautions throughout our office to prevent exposure to the COVID-19 Virus. Please be advised of the following:

  • While our office complies with State Health Department and Centers for Disease Control (CDC) guidelines and prevention guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

  • Our staff presents symptom free and to the best of their knowledge have not been exposed to the virus. However, because we are a public accommodation and persons (including other patients) could be infected with or without their knowledge.

In order to reduce the risk of spreading the COVID-19, we have asked you several screening questions at the time of confirmation of the appointment and when you presented for the appointment. For the safety of our staff, other patients and you, please be candid and truthful in your answers.

By submitting the form below, I certify that I have been truthful and the information is correct to the best of my knowledge.

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Do you/they have a cough?
Have you/they experienced recent loss of taste or smell?
Are you/they having shortness of breath or other difficulties breathing?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
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.
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)

Thanks for submitting!

Dental Tools in Pocket

Find useful forms here.

Want to save some time when you get to the dental office? Download any of the forms needed below and fill out before you arrive! 

Patient Information Sheet

Medical History Form

HIPAA Notice of Privacy Practices