COVID Screening Form

Patient's Name*

Age*

Have you or your child had a COUGH, FEVER, RECENT LOSS of TASTE or SMELL, SORE THROAT , or SHORTNESS OF BREATH in the last 48 hours?*

Yes - Please do not enter the buildingNo

Have you or your child TESTED POSITIVE or been DIAGNOSED as having COVID-19, had CONTACT with a person infected with COVID-19 within the last 14 days?*

Yes - Please do not enter the buildingNo

Does your child have a chronic lung condition, heart disease, diabetes, or take an immune suppressive medication?*

YesNo

Has your child had any medical changes, including surgeries?*

YesNo

If so, what?

Is your child taking any medication at this time?*

YesNo

If so, what?

Has your child had radiation and/or chemotherapy within the last year?*

YesNo

Do you have concerns regarding your child's dental health?*

YesNo

If so, what?

Do you consent to diagnostic dental X-rays on your child today, if requested by the Doctor?*

YesNo

I hereby acknowledge and understand that there may be an increased risk that COVID-19 may be transmitted in any place of public accommodation, which includes my dentist’s office. I have been informed by my dentist of their desire to protect their patients, staff, and the community at large.

I agree to notify the dental practice if within 14 days I or my child becomes ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days

We kindly ask for at least 48 hours' notice for any appointment changes or cancellations. This allows us to offer appointment time to other patients in need of care.

Cleaning Appointments: A $100 fee will apply for missed or cancelled appointments without 48 hours' notice.
Operative Appointments (including fillings, crowns, extractions, etc.): A $200 fee will apply for missed or cancelled appointments without 48 hours' notice.
We understand that emergencies can happen. Please contact us as soon as possible if you are unable to attend your appointment. Thank you for your understanding and cooperation.

Parent/Guardian Signature*

Please Sign with Your Finger/Stylus

Relationship to Patient*

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