Dental Clinic Vaccination Assessment Form
Please complete this form to help us assess your vaccination status and suitability for dental treatment. All information is confidential and used solely for your care.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you received all recommended childhood vaccinations (e.g., MMR, DPT, polio)?
*
Yes
No
Not sure
Have you received the influenza (flu) vaccine within the past year?
*
Yes
No
Not sure
Have you received the COVID-19 vaccine?
*
Yes, fully vaccinated
Yes, partially vaccinated
No
Please indicate your agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel well enough for dental treatment today.
1
2
3
4
5
I understand the importance of vaccinations for my health.
6
7
8
9
10
I have not had any recent fever or illness.
11
12
13
14
15
Do you have any known allergies to vaccines or medications?
*
No
Yes (please specify below)
If yes, please specify your allergies:
Have you had close contact with anyone diagnosed with a contagious disease (e.g., COVID-19, measles) in the past 14 days?
*
Yes
No
Not sure
Submit Assessment
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