APPOINTMENT SCREENING QUESTIONNAIRE

TO BE COMPLETED BY ALL PATIENTS

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.
PLEASE COMPLETE WITHIN 24 HOURS OF YOUR APPOINTMENT.
THANK YOU!
 
 
Do you have a fever or have you felt feverish recently?


Do you have a dry cough?
 
 
Are you having shortness of breath or any difficulty breathing?
 
 
Do you have chills or repeated shaking with chills?
 
 
Do you have any new muscle pain?
 
 
Do you have any recent onset of headache or sore throat?
 
 
Do you have any other flu-like symptoms?
 
 
Do you have any recent loss of taste or smell?


Have you experienced any recent GI upset or diarrhea?


Have you tested positive for COVID‐19?


Have you been in contact with someone who has tested positive for
COVID‐19?
IF YOU ANSWERED "YES" TO ANY OF THE ABOVE, PLEASE CALL OUR OFFICE. 651-426-8998.
 

Are you over age of 65?
Please Note that other family members will not be allowed in the treatment room.  In the case of a minor, one parent will be allowed to accompany the patient.
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.