Patient Screening (ADA Code D0190)
Dentists are required by the State of Colorado, following recommendations of the CDC, to screen patients before each appointment. If you have symptoms of COVID-19 we will be happy to assist you with rescheduling. Our waiting room is closed to the public by State mandate. Only those with an appointment may enter. Our team will text you when your treatment room is ready. We truly appreciate your willingness to help track/mitigate the community spread of corona virus. Best Regards, Clifford B. Cappelli DMD
Name
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First Name
Last Name
Email
example@example.com
What service will you receive at your visit today? (Important: be sure to let us know if you are experiencing pain, trauma, inflammation, or infection.)
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Do you have any symptoms of COVID-19 (dry cough, shortness of breath, nasal congestion, loss of taste or smell, fever of 100 degrees or higher, chills, sore throat, muscle aches)
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Yes
No
Please describe your symptoms
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
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Yes
No
Please explain your Yes answer:
Have you traveled outside of the US or to COVID-19 hot spots within the US within the last 14 days?
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Yes
No
Please indicate where you have traveled:
Have you been exposed to anyone with COVID-19 within the past 14 days?
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Yes
No
Have you been tested since having contact? What was the result of your test?
Are you over age 60?
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Yes
No
Signature
*
Required
Submit
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