OperaDDS - Form

APPOINTMENT SCREENING QUESTIONNAIRE

TO BE COMPLETED BY ALL PATIENTS

MASKS ARE STILL REQUIRED IN OUR OFFICE BY THE CDC

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.

PLEASE COMPLETE WITHIN 24 HOURS OF YOUR APPOINTMENT.

THANK YOU!

Do you have any of the following? Fever, dry cough, shortness of breath, chills, sore throat, flu-like symptoms, or new onset of loss of taste OR smell?

If yes, when?

Have you tested positive for COVID‐19 in the last 2 weeks?

If yes, when?

Have you been in contact with someone who has tested positive for
COVID‐19 in the last 2 weeks?

If yes, when?

IF YOU ANSWERED "YES" TO ANY OF THE ABOVE, PLEASE CALL OUR OFFICE. 651-426-8998.

The COVID-19 virus is a serious and contagious disease. The World Health Organization has classified it as a pandemic. I could contract COVID from a variety of sources. White Bear Smiles, P.A. wants to ensure that I am aware of the additional risks of contracting COVID-19 while receiving dental care.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.

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