Covid-19 Patient Screening Form
Instructions for use: Use one form for each patient appointment. Ask the patient these questions at the time appointment is made or with appointment reminder, and again no more than two days before the appointment. Take the patient’s temperature and note any signs of fever, coughing, or shortness of breath.
Patient/Parent/Guardian Names: _____________________________________________
Patient signature required at appointment:
I agree to notify the dental practice if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days.
Signature: _________________________________ Date: _____________