Patient Screening Form/Forma de Detección

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Patient Name:
PRE-APPOINTMENT DATE
IN-OFFICE DATE
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
PRE-APPOINTMENT
IN-OFFICE
Are you/they having shortness of breath or other difficulties breathing?
PRE-APPOINTMENT
IN-OFFICE
Do you/they have a cough?
PRE-APPOINTMENT
IN-OFFICE
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
PRE-APPOINTMENT
IN-OFFICE
Have you/they experienced recent loss of taste or smell?
PRE-APPOINTMENT
IN-OFFICE
Are you/they in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
PRE-APPOINTMENT
IN-OFFICE
Is your/their age over 60?
PRE-APPOINTMENT
IN-OFFICE
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
PRE-APPOINTMENT
IN-OFFICE
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
PRE-APPOINTMENT
IN-OFFICE
Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing, see the list of State and Territorial Health Department Websites for your specific area’s information.​​​​​​​