COVID-19 Patient Pre-Screening Form Must be submitted within 7 days to 24 hours prior to your dental appointment. Name:*Temp:*Date:* Date Format: MM slash DD slash YYYY Screened by:Pre-Appointment Date:* Date Format: MM slash DD slash YYYY In-Office Date: Date Format: MM slash DD slash YYYY Person Responsible for Account:Name:Relationship to patient:Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 1. Do you have fever or have you felt hot or feverish recently (14-21 days)?PRE-APPOINTMENT*YesNoIN-OFFICEYesNo2. Are you having shortness of breath or other difficulties breathing? PRE-APPOINTMENT*YesNoIN-OFFICEYesNo3. Do you have a cough?PRE-APPOINTMENT*YesNoAllergies: IN-OFFICEYesNo4. Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?PRE-APPOINTMENT*YesNoList Symptoms IN-OFFICEYesNo5. Have you experienced recent loss of taste or smell?PRE-APPOINTMENT*YesNoIN-OFFICEYesNo6. Have you been in contact with any confirmed COVID-19 Positive patients?PRE-APPOINTMENT*YesNoDate of contact:Were you tested?YesNoType of Covid Test Swab / Antibody:Results of Covid Test + / -IN-OFFICEYesNoDate of contact:Were you tested?YesNoType of Covid Test Swab / Antibody:Results of Covid Test + / -7. Are you over the age over 60?PRE-APPOINTMENT*YesNoIN-OFFICEYesNo8. Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?PRE-APPOINTMENT*YesNoIf yes:IN-OFFICEYesNoIf yes:9. Have you traveled out of Santa Clara County in the past 14 days? PRE-APPOINTMENT*YesNoWhere?IN-OFFICEYesNoWhere?Email: Signature (Patient/Parent/Guardian):*The signer must be 18 years or older.Children under 18 need a parent signature. If under 18, please print name & relationship below:Name:Relationship with patient:
