Pre-Appointment Patient Screening Form

Have you had a fever or above normal temperature within past 14-21 days? YesNo
Have you experienced shortness of breath or had trouble breathing within past 14-21 days? YesNo
Do you have a dry cough? YesNo
Do you have a runny nose? YesNo
Have you recently lost or had a reduction in your sense of smell? YesNo
Do you have a sore throat? YesNo
Have you been in contact with or have a sick family member at home who has tested positive for COVID‐19 within the past 14 days? YesNo
Have you tested positive for COVID‐19? YesNo
Have you been tested for COVID‐19 and are awaiting results? YesNo
Have you traveled by plane, train or charter bus within the past 14 days? YesNo
Do you have any flu-like symptoms? YesNo

This screening and consent document is designed to obtain information from you that we must consider before making treatment decisions during the COVID-19 pandemic. It also provides information for you regarding the COVID-19 virus and your dental treatment. Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community.

The COVID-19 virus is a contagious disease. Our practice wants to inform you of the possible risk of contracting COVID-19 associated with dental care. Some dental procedures create water spray which is one way the disease is spread. To reduce risk to both you and your dental providers, this practice follows the requirements for infection control developed by regulatory agencies including the MN Board of Dentistry, CDC, OSHA and the Department of Health.

I confirm that I understand the information above and accept there is a risk of contracting COVID-19 virus associated with dental treatment. An individual could contract COVID-19 from a variety of sources. I also acknowledge I could contract COVID-19 from a source outside this office and unrelated to my visit here.

By signing this document, I acknowledge that the answers I have provided above are true and accurate and I consent to dental care.