Covid-19 Patient Screening Form
Do you have a fever or above normal temperature (> 100.0° F)?
Are you experiencing shortness of breath or having trouble breathing?
Do you have a dry cough?
Do you have a runny nose?
Have you recently lost or had a reduction in your sense of smell or taste?
Do you have a sore throat?
Are you experiencing chills or repeated shaking with chills?
Do you have unexplained muscle pain?
Do you have a headache?
Are you experiencing nausea, vomiting or diarrhea?
Even if you don't currently have any of the above symptoms, have you experienced any of these symptoms within the last 14 days?
Have you been in unprotected contact with someone who has tested positive for COVID-19 in the last 14 days? *"Unprotected contact" means without the use of personal protective equipment.
Have you been tested for COVID-19 in the last 14 days?
lf yes, what is the result of the testing?
Are you fully vaccinated for COVID-19?
Have you traveled more than 100 miles from your home in the last 14 days?

Patient signature required at appointment:

I agree to notify the dental practice if within 2 days I become 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 personnel I had close contact with, tested positive for COVID-19 within 2 days.

Acepto dar aviso a la clinica dental si dentro de dos dias presento sintomas de COVID-19 o tengo un resultado positivo de COVID-19. Entiendo que la clinica dental tiene la obligacion legal y etica de informarme si un miembro del personal con el que tuve contacto ha tenido un resultado positivo de COVID-19 dentro de dos dias.