Pre-Appointment Questionnaire COVID-19 Consent

Pre-Appointment Questionnaire

COVID-19 Pandemic Dental Treatment Consent Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number

Area CodePhone Number
Are you vaccinated?

YesNo
Date of Last Vaccine

MonthDayYear
Do you have a fever, or have you felt feverish recently?*

YesNo
Do you have a cough?*

YesNo
Are you having shortness of breath or any difficulty breathing?*

YesNo
Do you have chills or repeated shaking with chills?*

YesNo
Do you have any muscle pain?*

YesNo
Do you have any other flu-like symptoms?*

YesNo
Do you have any recent onset of headache or sore throat?*

YesNo
Do you have any recent loss of taste or smell?*

YesNo
Have you experienced any recent GI upset or diarrhea?*

YesNo
Are you in contact with anyone who has been confirmed to be COVID-19 positive?*

YesNo
If yes, are you a health care provider that uses PPE?

YesNo
Have you traveled in the past 14 days to any regions affected by COVID-19?*

YesNo
Are you over the age of 65?*

YesNo
Do you have?*

Heart diseaseLung diseaseKidney diseaseDiabetesAutoimmune disordersNone of the above
COVID-19 Pandemic Dental Treatment Consent Form (3 of 4)
Patient's Name*
I knowingly and willingly consent to having emergency and/or elective dental treatment completed during the COVID-19 pandemic.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. Given the current limits in virus testing, it is impossible to determine who has it and who does not have COVID-19.

Dental procedures create water spray (aerosols), which is one way the disease can be spread. The ultra-fine nature of the spray can linger in the air for several minutes to hours, which can transmit the COVID-19 virus.
I understand that due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office. (Initial)
Initials*

Clear
I have been made aware of the Centers for Disease Control and Prevention (CDC) and American Dental Association (ADA) guidelines that under the current pandemic all non-urgent dental care is not recommended. Dental visits should be limited to the treatment of pain, infection, conditions that significantly inhibit normal operation of teeth and mouth, and issues that may cause anything listed above during the next 3-6 months.
Initials*

Clear
Have you had COVID 19 or been diagnosed with COVID 19 antibodies?

YesNo
I confirm I am seeking treatment for a condition that meets these criteria.
Initials*

Clear
I understand that air travel significantly increases the risk of contracting and transmitting the COVID-19 virus. The CDC recommends social distancing of at least 6 feet for a period of 14 days around anyone who has traveled by air, and this distance is not possible with dentistry.
Initials*

Clear
I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:
- Fever
- Shortness of breath
- Dry cough
- Runny nose
- Sore throat
Initials*

Clear
I verify that I have not traveled outside the United States during the past 14 days to countries that have been affected by COVID-19.
Initials*

Clear
I verify that I have not traveled within the United States by commercial airline, bus, or train within the past 14 days.
Initials*

Clear
Follow Up Appointment

I verify that there have been no changes to this questionnaire since my last dental appointment
Signature

Clear
Date

MonthDayYear
Should be Empty:

Pre-Appointment Questionnaire

COVID-19 Pandemic Dental Treatment Consent Form (3 of 4)