Patient Screening Form COVID-19

    Please Fill All The Details




    PatientCaregiver / Legal Guardian / Parent

    1.

    Pre-Screen

    YesNo

    2.



    Pre-Screen

    PositiveNegetiveNever Tested

    3.

    Pre-Screen

    YesNo

    4.

    Pre-Screen

    YesNo

    5.

    Pre-Screen

    YesNo

    6.

    Pre-Screen

    YesNo

    COVID-19 Pandemic Dental Risk

    Please read the patient acknowledgement below, and initial or sign in all areas indicated








    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.