PATIENT SCREENING FORM

Patient Signature:

Date:

PRE-APPOINTMENT

IN-OFFICE

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

Yes No

Do you have a cough?

Yes No

Are you having shortness of breath or any difficulties breathing?

Yes No

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

Yes No

Have you experienced recent loss of taste or smell?

Yes No

Have you been in contact with anyone who has been confirmed to be COVID-19 positive? Within the last 2 weeks. Patients who are well but who have a sick family member at home with COVID-19 will be rescheduled.

Yes No

Have you been tested for COVID-19? If yes, what was the result?

Yes No

Have you been diagnosed with COVID-19? If yes, when?

Yes No

When:

Yes No

When:

Is your age over 60?

Yes No

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

Yes No

Have you traveled out of the country in the past 14 days?

Yes No

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

Please note that there will now be a $10 COVID-19 PPE (Personal Protective Equipment) Surcharge for all appointments.

Please kindly give 48 hours advanced notice if you cannot keep your appointment. There is a $50 fee per 60 min that will be charged to your account for the time reserved for appointments missed or cancelled without 48 hours advanced notice given. If you are late to an appointment, please understand that your appointment may be shortened or rescheduled.