covid pre screen formCovid-19 Patient Pre-Screening FormDate* Patient Name* First Last Patient Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Cell PhoneHave you received any of the Covid-19 vaccinations?* First shot Second shot Fully vaccinated (It has been 2 weeks or more following your 2nd shot) N/A Do you have a fever or have you felt hot or feverish recently? Yes No Do you have a cough, experiencing any shortness of breath or other difficulties breathing? Yes No Have you experienced recent loss of taste or smell? Yes No Have/Are you in contact with any confirmed COVID-19 positive patients? Yes No Patients who are well but who have knowingly been in contact with someone with COVID-19 should consider postponing elective treatment.Have you been asked to quarantine for any reason? Yes No Have you been tested for Covid-19? Yes No If yes, what were your results? Positive Negative Awaiting Results N/A Additional NotesPositive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.• For testing, see the list of State and Territorial Health Department Websites for your specific area’s information.Please make sure to click SUBMIT and then PLEASE advance to the next page to update our General Consent form to avoid doing so in office. Thank you!NameThis field is for validation purposes and should be left unchanged.