Patient Screening Form
Please answer the following questions for yourself, your children and your immediate family.
Patient First Name
Patient Last Name
Date Of Birth
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Are you/they having shortness of breath or other difficulties breathing?
Do you/they have a cough or 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.
Is your age over 60?
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Positive responses to any of these would likely indicate postponing this appointment for at least 14 days before proceeding with elective dental treatment.
Patient/Legal Guardian Signature
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