Dental COVID-19 Screening and Consent Form
Please complete this form before your dental visit so the clinic can review your health screening and visit readiness.
Patient Information
Patient Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
COVID-19 Screening
Do you have any COVID-19 symptoms today?
*
No symptoms today
Mild symptoms
Moderate or severe symptoms
Have you had close contact with someone diagnosed with COVID-19 recently?
*
No
Yes
Have you tested positive for COVID-19 recently?
*
No
Yes
Current body temperature (°F)
Consent and Visit Readiness
COVID-19 screening acknowledgement
*
I confirm the information I provided is accurate and I understand my dental visit may be rescheduled if I report symptoms, exposure, or a recent positive test
I do not confirm the screening information is accurate or I am not ready to proceed with the dental visit
Visit readiness / preferred appointment date
*
Please Select
Ready to proceed now
Prefer to schedule for a later date
Prefer a specific appointment date
Submit
Should be Empty: