Form

COVID‐19 PANDEMIC ‐ PATIENT SCREENING FORM

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First

Last

Pre-Appointment

In-Office

Date

Do you have fever or have you felt hot or feverish recently (14-21 days)?

Are you having shortness of breath or other difficulties breathing?

Do you have a cough?

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Have you experienced recent loss of taste or smell?

Are you 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 have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Have you been with anyone who's had signs of a cold or signs of Covid-19 in the past 14 days?

Have you been with anyone who has flown in the past 14 days?

Have you flown in the past 14 days?

If yes, where?

If yes, when did you return to New York City?

Have you been out of the Tri-state area in the past 14 days?

If yes, where?

If Yes, when did you return to New York city?

Are you fully vaccinated for Covid-19?

First Shot

Second Shot

Additional information for fully vaccinated patients ( optional )

This section will be completed by your dentist or staff menber on the day of your appointment. Please sign this form using the "Sign here" button in the area below.

Temperature registered when arriving to office:

Oxigen level registered when arriving to office:

For testing, see the list of State and Territorial Health Department Websites for your specific area's information.

Signature

Date