Covid-19 Screening Date / Time *Patient Full Name *Please read the patient acknowledgement below, and initial or sign in all areas indicated.Pre-ScreenDo you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19? YesNoDo you have any of the following symptoms: Fever, New Onset Cough, Worsening Chronic Cough, Shortness Of Breath, Sore Throat, Difficulty Swallowing, Decrease Or Loss Of Sense Of Taste Or Smell, Chills, Headaches, Unexplained Fatigue - Malaise - Muscle Aches, Nausea, Vomiting, Diarrhea, Abdominal Pain, Pink Eye, Running Nose, Nasal Congestion Without Other Known Cause? YesNoAre you 70 years of age and experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? YesNoPatient AcknowledgementAny "Yes" responses must be discussed with the managing dentist prior to your appointment.I, (initial) I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic. *Patient Signature * MessageSubmit
