OperaDDS - Form

COVID‐19 PATIENT SCREENING & DISCLOSURES

Office Protocols:

Mask are still required for all over the age of 2 who enter the building regardless of vaccination status.
For 9:00 AM or 2:00PM appointments, please do not come in the office until exactly 9:00 AM or 2:00PM.
This screening form is required BEFORE entering the office at every appointment.
Only scheduled patients are allowed inside the office and ONE adult per family may accompany the patient(s). If one adult is needed per child please contact the office directly to schedule accordingly.
DO NOT call or text when you arrive, just come in at your appointment time. Enter no more than 5 minutes early to limit time spent in the waiting room.
Once inside hand sanitizer is required before being seated.

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 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.

How many children have an appointment on the same day?

Child First Name (1)

Child Last Name (1)

Has this child (1) received a COVID-19 vaccination?

Child First Name (2)

Child Last Name (2)

Has this child (2) received a COVID-19 vaccination?

Child First Name (3)

Child Last Name (3)

Has this child (3) received a COVID-19 vaccination?

Child First Name (4)

Child Last Name (4)

Has this child (4) received a COVID-19 vaccination?

Child First Name (5)

Child Last Name (5)

Has this child (5) received a COVID-19 vaccination?

Child Name (6)

Child Last Name (6)

Has this child (6) received a COVID-19 vaccination?

Has the patient(s) have/had a dry cough within the past 10 days?

Please explain:

Has the patient(s) have/had a fever within the past 10 days?

Please explain:

Has the patient(s) experienced shortness of breath or had trouble breathing within the last 10 days?

Please explain:

Has the patient(s) have/had any flu like symptoms within the past 10 days?

Please explain:

Has the patient(s) recently lost or had a reduction in your sense of smell within the past 10 days?

Please explain:

Has the patient(s) have/had a sore throat within the last 10 days?

Please explain:

Has the patient(s) or anyone in the household been in contact with someone who has tested positive for COVID‐19 in the last 30 days?

If so, enter date:

Has the patient(s) or household member since been tested for this occurrence? If so, when and what was the result?

Has the patient(s) been tested for COVID‐19 in the last 30 days?

If so, enter date and results:

Has the patient(s) or anyone in the household been tested for COVID‐19 and are awaiting results?

Please explain:

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 or 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.

Signature

Date

Parent or Guardian First Name

Parent or Guardian Last Name

Best Family Cell Phone

Best Family Email

This communication is secure and encrypted for your protection. Once submitted it is sent directly to the office. It may contain protected health information (PHI) that is legally protected from inappropriate disclosure by Privacy Standards of Health Insurance Portability and Accountability (HIPAA) and relevant Virginia Laws.