Form

Curbside Check-In & COVID‐19 Pre-Screen Disclosures

Please fill out this form on the day of your appointment

AND THEN PROCEED TO THE WAITING ROOM

IF YOU HAVE NO SUCH SYMPTOMS

You may

Text 724-819-2843 or Call 724-663-7735

upon your arrival if you have questions or any such symptoms!

Thank you for understanding our ongoing requirement to pre-screen prior to all dental appointments.

*This form can also be filled out at www.LindseyDentistry.com/checkin

Please Check-In!

PLEASE CHECK IF YOU HAVE ARRIVED FOR YOUR APPOINTMENT:

When completing this form, I am answering EACH question for EVERYONE entering the Dental Office, which includes:

OTHER:

Additional Name 1:

Additional Name 4:

Additional Name 2:

Additional Name 5:

Additional Name 3:

COVID-19 Prescreen Disclosures

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

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.

I am completing these answers for ALL persons listed above.

SYMPTOMS

Please disclose if you have ANY of the following Symptoms?

1. Fever or above normal temperature?

"Normal" body temperature can have a wide range, from 97°F to 99°F.

A temperature over 100.4°F (38°C) most often means you have a fever caused by an infection or illness.

2. Have you recently experienced shortness of breath or trouble breathing?

3. Do you have a dry cough?

4. Do you have a runny nose or a cold?

5. Do you have a soar throat?

6. Have you recently lost or had a reduction in your sense of smell?

Are you experiencing any of these SIX Symptoms

ONLY IF you have answered YES to any of the above SIX symptoms, Please check all applicable symptoms you or your accompanying guests are experiencing

Exposure

Please answer if any of any of these COVID-19 and Travel screeeings apply to you.

1. IN THE LAST 14 DAYS, Have you been in prolonged contact with someone who has tested positive for COVID‐19?

2. In the last 30 days, have you tested positive for COVID-19?

3. Have you recently been exposed to Covid-19 and are wating test results?

4. Have you traveled outside of the United States or to a known area with high occurrences in the last 14 days?

Have you experienced any of the FOUR Covid-19, Contact, & Travel Exposures

ONLY if you have answered YES for any of the above Covid-19, Exposure, or Travel screenings, please check all that apply for you and your accompanying guests.

If YES, please comment.

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate for all persons entering the facility.

Please be sure to: 1.) ENTER FIRST & LAST Name 2.) SIGN 3.) THEN press the "SUBMIT" button below.

First

Last

Signature

Date

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