Form

1229 Silver Lane, Suite 2
McKees Rocks, PA 15136
Tel: (412) 859-3199
E-Mail: info@terrificteethpd.com

COVID‐19 Questionnaire

This patient disclosure form seeks information from you about your child 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 your child at greater risk for contracting COVID‐19. Please disclose to us any condition that compromises your child's 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 your child having been exposed to COVID‐19, or whether your child or other immediate family members have experienced any signs or symptoms associated with the COVID‐19 virus.

First Name

Last Name

Date Of Birth

Does your child have a fever or above normal temperature?

Has your child experienced shortness of breath or had trouble breathing?

Does your child have a dry cough?

Has your child recently lost or had a reduction in sense of smell?

Does your child have a sore throat?

Has your child been in contact with someone who has tested positive for
COVID‐19 in the past 5 days?

Has your child recently been tested for COVID‐19 and are awaiting results?

Has your child tested positive for COVID‐19 in the past 5 days?

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 child's 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.

Person Completing this Form

Patient/Parent/Guardian Signature

Date

Anyone over the age of 2 please wear a mask.

If anyone has any questions or concerns related to our COVID-19 protocols, please feel free to call in advance and we are more than happy to discuss with you.