Form

COVID‐19 PANDEMIC ‐ SCREENING FORM REQUIRED TO ENTER THIS FACILITY

If completing form on cellular device or small screen, view in landscape mode (horizontal screen view) by rotating your phone.

PLEASE LIST EACH PERSON ENTERING THIS FACILITY.

In-Office

Date

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

Do you/they have a cough?

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 a deeper discussion with the staff before proceeding with elective dental treatment.

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

Patient / Legally Authorized Representative Signature

Date