Interim COVID-19 Pre-Appointment Screening Form

Interim COVID-19 Pre-Appointment Screening

Rest assured, we are taking the COVID-19 pandemic situation seriously. We practice Universal Precautions EVERY DAY, but we do have some small changes to relay to our patients.

· All patients will be required to wash their hands thoroughly when they arrive.
· We ask that patients come alone, children with one parent, to decrease numbers in our reception area
· We ask patients to NOT come early to their scheduled appointment. If you do arrive early, we ask that you wait in your car until your scheduled appointment time.
· We have removed all magazines and shared items from our reception area and operatories.
· A patient may be asked to reschedule if any positive answers are provided to this questionnaire or if you have a high temperature above 100.4.
· All common touchpoints in the lobby such as door handles, counters, chair arms, etc. will be disinfected frequently.
· We ask patients to contact our office if they experience COVID-19 symptoms within 14 days after dental appointment.
· We ask all patients to fill out this form the DAY OF your appointment and record your temperature.

Full Name*

First NameLast Name

Date*

Date

Day of appointment at home recorded temperature*

Have you tested positive for COVID-19?*

YesNo

Have you been tested for COVID-19 and are awaiting results?*

YesNo

Do you have fever or have you felt hot or feverish recently (14-21 days)?*

YesNo

Are you having shortness of breath or other difficulties breathing?*

YesNo

Do you have a cough?*

YesNo

Any other flu like symptoms, such as GI upset, headache, or fatigue?*

YesNo

Have you experienced recent loss of taste or smell?*

YesNo

Have you been in contact with any confirmed COVID-19 positive patients?*

YesNo

Have you traveled by air, bus, or train within the last 14 days?*

YesNo