COVID-19 Screening Form
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 (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 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.

Within the last 10 days have you been diagnosed with COVID-19 or had a test confirming you have the virus?

Within the past 14 days, have you had close contact with anyone that you know had COVID-19 or COVID-like symptoms?  Close contact is defined as being 6 feet or closer for more thmn 15 minutes total in a 24-hour period?
Have you had any one or more of these symptoms today or within the past 24 hours?

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 also agree to notify the office if within 14 days I become ill with COVID-19.  I understand the dental practice has a legal and ethical obligation to inform me if a staff person I have contact with tests positive for COVID-19 within 14 days of my visit.