COVID-19 Patient Pre-Screening FormCovid-19 Patient Pre-Screening FormDate* Patient Name* First Last Patient Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PhoneDo you have a fever or have you felt hot or feverish recently (14-21 days)?* Yes NoDo you have a cough, experiencing any shortness of breath or other difficulties breathing?* Yes NoHave you experienced recent loss of taste or smell?* Yes NoAre you in contact with any confirmed COVID-19 positive patients?* Yes NoPatients 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?* Yes NoIf yes, please explain:Have you been tested for Covid-19?* Yes NoIf yes, what were your results?* Positive Negative Awaiting Results N/AHave you traveled in the past 14 days to any high risk regions affected by COVID-19? (as relevant to your location)* Yes NoAdditional 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 SUBMITPhoneThis field is for validation purposes and should be left unchanged.