Patient Form

Patient Screening Consent Form

I, knowingly and willingly Consent to have dental treatment completed during the COVID-19 pandemic and health crisis.

COVID-19 is highly transmissible and serious infection that may require hospitalization and could result in death.

First Name *

Last Name *

Phone *

Fever or feverish over the past 14-21 days?

Shortness of Breath or difficulties breathing?

Dry Cough? Runny Nose? Sore Throat?

Flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Recent loss of taste or smell?

In contact with any confirmed COVID-19 positive patients?

Are you over the age of 65?

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Consent *

I also verify that I have not traveled within or outside the United States in the past 14 days to any regions affected by COVID-19

Patient Signature *

Date *

Witness Signature *

Date *

Comment