Patient Screening Form

{practiceName}

Patient Consent and Screening Form

Account ID*

Env*

Practice Name*

Practice Recipient Email*

Patient Name*

First NameLast Name

Date of Birth*

Phone Number*

Patient Consent Form

I understand the novel coronavirus causes the disease known as COVID-19. Symptoms may include (but are not limited to): fever, cough, sore throat, shortness of breath, difficulty breathing, flu-like symptoms, runny nose, loss of taste/smell, chills, fatigue, rash.

I have considered whether I am in a high-risk category, including (but not limited to): diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, active cancer, over age 65.

I understand that due to the characteristics of the COVID-19 and the limitations on physical distancing when out in public and during dental procedures, that there is a risk of contracting COVID-19, especially where local prevalence rates are high.

I understand that the dental practice is following all infection prevention and control guidelines in order to minimize the risk to patients, the dental team, and the community.

I understand that there may be modifications to appointment scheduling, available treatment options, and office protocols during the pandemic to help eliminate the spread of the virus.

Acknowledgement and Consent*

	I Acknowledge
I have received information about COVID-19 including its symptoms and risk factors.
I have informed the dental practice if I have ANY symptoms or risk factors.
I understand the risk of transmission in a dental office can be minimized by infection prevention and control measures but it cannot be completely eliminated.
I know it is my right to ask questions about COVID-19 and have them answered to my satisfaction.
I consent to and wish to proceed with the procedures.

Patient Screening Form

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 chills Cough 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*