COVID-19 - Quick-Screening

Dear Patient: You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic.
Please be advised of the following:

• While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.
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• Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.

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Please indicate if you answer YES to any of the following;

• DO YOU HAVE A FEVER?
• DO YOU HAVE ANY SHORTNESS OF BREATH?
• DO YOU HAVE A DRY COUGH?
• DO YOU HAVE A RUNNY NOSE?
• DO YOU HAVE A SORE THROAT?
• DO YOU HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURE THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES?
• HAVE YOU EXPERIENCED HEADACHES, FATIGUE, OR WEAKNESS?
• HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL?
• WITHIN THE LAST 14 DAYS HAVE YOU TRAVELED OUT OF THE STATE/COUNTRY?
• WITHIN THE LAST 14 DAYS HAVE YOU TRAVELED BY AIRPLANE?
• WITHIN THE LAST 14 DAYS HAVE YOU HAD CLOSE CONTACT WITH A PERSON WHO HAS CONFIRMED OR SUSPECTED POSITIVE COVID-19?

NO, NONE OF THE ABOVE APPLY TO ME

YES, ONE OR MORE OF THE ABOVE APPLY TO ME