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Dental Patient Screening Form

Patient Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Do you/they have fever or chills or feverish recently (14-21 days)?(Required)
Are you/they having shortness of breath, chest pain or other difficulties breathing?(Required)
Do you/they have a cough, sore throat, sneeze, congestion or runny nose?(Required)
Any other flu-like symptoms, such as headache, bodyache, fatigue, nausea, vomitting or Diarrhea?(Required)
Have been in contact with any confirmed COVID-19/Delta/Omicron positive patients or with who has cold/flu within 14 days?(Required)
Patients who are well but who have a family member at home with positive covid-19 or with cold/flu symptoms should consider postponing elective treatment
Do you/they have Asthma, heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?(Required)
Have you/they gotten tested for COVID-19 in last 14 days?(Required)
Have you/they traveled outside of the country in the past 21 days?(Required)

Positive responses to any of these would likely indicate a deeper discussion before proceeding with scheduled visit and possible to be rescheduled.
**Face Masks Not Required But Recommended**