Form

Medical History Update & COVID-19 Screening

Your mouth is part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important relationship with the dentistry you will receive. Thank you for answering the following questions.

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

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.

Within the past 10 days have you tested positive for COVID-19?

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

Today are you experiencing a cough, runny nose, sore throat, fever, or loss of smell?

Within the past 10 days has someone you have been in close contact with tested positive for COVID-19? (examples: live in same household, someone you provide care for, significant other)

Have you had any changes in your medical history in the past 6 months?

If Yes, Please Explain

Are you allergic to any of the following?

Do you have any other allergies?

If yes, what?

Have you ever had a joint replacement?

(Knee, hip, shoulder)

Are you taking blood thinners?

Do you use tobacco products or Vape?

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.

I consent to the diagnostic procedures and treatment by the dentists of this office necessary for proper dental care.

Patient's First Name

Patient's Last Name

Phone

Have you had a change of address since you were last at Summit Dental? If yes, please inform our front desk staff when you arrive.

Signature of Patient or Legal Guardian (if under 18)

Date