Trung Quoc Lam, DDS, PC Covid-19 Screening Questionnaire Name* First Last Date Of Birth* Month Day Year Have you been completely vaccinated for COVID-19?* YES NO PREFER NOT TO ANSWER Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?* YES NO Are you/they having shortness of breath or other difficulties breathing?* YES NO Do you/they have a cough?* YES NO Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?* YES NO You selected YES, Please provide more details* Have you/they experienced recent loss of taste or smell?* YES NO Are you/they in contact with any confirmed COVID-19 positive patients?* YES NO Is your/their age over 60?* YES NO Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?* YES NO Have you/they traveled in the past 14 days outside your state? (as relevant to your location)* YES NO Where have you traveled to?* Have you been tested positive to COVID-19?* YES NO When did you get tested positive to COVID-19?* Month Day Year Have you been tested again as negative to COVID-19?* YES NO When did you get tested negative to COVID-19?* Month Day Year Patients who are well but who have a sick family member at home with COVID-19 should consider postponing/rescheduling treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with dental treatment.COVID-19 Treatment Consent Form*Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the COVID‐19 virus. The COVID‐19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID‐19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting COVID‐19 associated with dental care. The COVID‐19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID‐19 is challenging and complicated due to limited availability for virus testing. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office. Dental procedures create water spray which is one way the disease is spread. The ultra‐fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID‐19 virus to those nearby. You cannot wear a protective mask over your mouth to prevent infection during treatment as your health care providers need access to your mouth to render care. This leaves you vulnerable to COVID‐19 transmission while receiving dental treatment. Pursuant to statements from the Center for Disease Control (CDC) and the American Dental Association (ADA), non‐essential or elective treatment, based on the assessment of our staff, will be rescheduled. According to the ADA, dental emergencies are “potentially life threatening and require immediate treatment to stop ongoing tissue bleeding [or to] alleviate severe pain or infection.” The ADA also recommends that urgent dental care which “focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments” be provided in as minimally invasive a manner as possible. I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I further confirm I am seeking treatment for a condition that meets the emergent or urgent criteria noted above. I understand and accept the additional risk of contracting COVID‐19 from contact at this office. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here. I agree to above mentioned consent.Signature of Patient or Legal Guardian*Today's Date: 11/25/2025HiddenUsernameThis is a hidden field HiddenConsent TextOur goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the COVID‐19 virus. The COVID‐19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID‐19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting COVID‐19 associated with dental care. The COVID‐19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID‐19 is challenging and complicated due to limited availability for virus testing. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office. Dental procedures create water spray which is one way the disease is spread. The ultra‐fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID‐19 virus to those nearby. You cannot wear a protective mask over your mouth to prevent infection during treatment as your health care providers need access to your mouth to render care. This leaves you vulnerable to COVID‐19 transmission while receiving dental treatment. Pursuant to statements from the Center for Disease Control (CDC) and the American Dental Association (ADA), non‐essential or elective treatment, based on the assessment of our staff, will be rescheduled. According to the ADA, dental emergencies are “potentially life threatening and require immediate treatment to stop ongoing tissue bleeding [or to] alleviate severe pain or infection.” The ADA also recommends that urgent dental care which “focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments” be provided in as minimally invasive a manner as possible. I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I further confirm I am seeking treatment for a condition that meets the emergent or urgent criteria noted above. I understand and accept the additional risk of contracting COVID‐19 from contact at this office. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here.HiddenHideAgeThis is a hidden field ← Hemal.patel85@gmail.com → How to have a healthy smile during this pandemic?
