Just Smilez Dental

Patient Screening Form

Patient Name

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

Pre-appointment

Yes

No
In-office
Yes

No

Are you/they having shortness of breath or difficulties breathing?

Pre-appointment
Yes

No
In-office
Yes

No

Do you/they have a cough?

Pre-appointment
Yes

No
In-office
Yes

No

Any other flu-like sympton, such as gastrointestinal upset, headache or fatigue?

Pre-appointment
Yes

No
In-office
Yes

No

Have you/they experienced the recent loss of taste or smell?

Pre-appointment
Yes

No
In-office
Yes

No

Are you/they in contact with any confirmed COVID-19 positive patients?

Pre-appointment
Yes

No
In-office
Yes

No

Is your/their age over 60?

Pre-appointment
Yes

No
In-office
Yes

No

Do you/they have hearth disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Pre-appointment
Yes

No
In-office
Yes

No

Have you/they traveled in the past 14 days to any regions affected by COVID-19?

Pre-appointment
Yes

No
In-office
Yes

No

Positive response to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

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Your legal name

Your email address

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Document name: Patient Screening Form

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Feb 25, 2022 1:01 pm CST

Patient Screening Form Uploaded by Dr. Divya Sankepally - info@justsmilezdental.com IP 45.44.67.113

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