PRE-APPOINTMENT SCREENING QUESTIONNAIRE FOR COVID-19
In an effort to keep our staff and other patients like yourself safe, we ask that you take the time to read through and answer this questionnaire before you visit our office. For the safety of all concerned, answering of this form is mandatory before you can be seen in the office. Thank you for your understanding.
- Do you or have you had any flu-like symptoms in the last 14 days?
- Shortness of Breath
- New loss of taste or smell
- Or at least two of these symptoms:
- Repeated shaking
- Runny nose
- Post-nasal drip
- Muscle aches
- Sore throat
- Malaise (general sense of feeling unwell)
- Swollen or red toes
- Are you awaiting results of a lab test for COVID-19?
- Have you tested positive for COVID-19? When?
- Have you or a family member previously been asked to self-isolate or self-quarantine in the past 14 days?
- Have you had close contact to an individual diagnosed with COVID-19 infection in the past 14 days?
- Have you traveled in the past 14 days to a region with high rates of COVID-19 disease activity?
If you answered yes to any of the above questions, please call the office immediately.
When you arrive at the office, you will be asked to sign a form attesting to these answers.
If you are at risk for severe COVID-19, you should consider delaying your appointment.
Patients considered high risk for severe COVID-19 include those with pre-existing conditions such as serious respiratory disease, serious heart conditions, immunocompromised conditions, severe obesity, diabetes, chronic kidney disease or those undergoing dialysis, and liver disease; pregnant patients; and patients who are 70 years and over. If you belong to one of these categories, and your dental need is not urgent, please let us know as we have set aside times and dates for those who are concerned. Also remember that dental disease left untreated can also be life threatening in severe cases. If unsure, please ask. Dental exams are low risk and should be done to rule out any more serious problems.