Patient Screening Form

{practiceName}

Account ID*

Env

Practice Name*

Practice Recipient Email*

Patient Name*

First NameLast Name

Date of Birth*

Phone Number*

Area CodePhone Number

1. Are you immunocompromised and/or live in a high-risk congregate care setting?*

YesNo

2. Do you have any of the below symptoms? Choose yes if you have one or more that are new, worsening and not related to other known causes or conditions.*

	Yes	No
Fever and/or chillsCough or barking cough Shortness of breath Decrease or loss of taste or smell Muscle aches/joint pain Extreme tiredness Sore throat Runny or stuffy/congested nose Headache Nausea, vomiting and/or diarrhea Abdominal pain Pink eye

3. Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority ) that you should currently be quarantining, isolating or staying at home?*

YesNo

4. In the last 10 days, have you tested positive for COVID-19on a laboratory-based PCR test, rapid molecular test, rapid antigen test orother home-based self-testing kit?*

YesNo

*Any “YES” response (other than Q1) must be discussed with the managing dentist immediately.

By signing this document, I acknowledge the importance of protecting the health of my dental provider and other patients. I confirm that all answers I have given above are true to the best of my knowledge.

Date*

Date

Signature*

Please verify that you are human*