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.
Positive responses to any of these would likely indicate postponing this appointment for at least 14 days before proceeding with elective dental treatment.
Have you received full vacination from an approved COVID-19 vaccine?
Patient/Legal Guardian Signature
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