Patient Screening Form
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Are you/they having shortness of breath or difficulties breathing?
Do you/they have a cough?
Any other flu-like sympton, such as gastrointestinal upset, headache or fatigue?
Have you/they experienced the recent loss of taste or smell?
Are you/they in contact with any confirmed COVID-19 positive patients?
Is your/their age over 60?
Do you/they have hearth disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you/they traveled in the past 14 days to any regions affected by COVID-19?
Positive response to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Patient Screening Form
Agree & Sign