Port Jefferson Smiles CORONA VIRUS 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 You selected YES, Please provide more details* 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 You selected YES, Please provide more details* 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 Have you/they traveled in the past 14 days outside your state of residence?* YES NO You selected YES, Please provide more details where have you traveled* Patients who are well but who have a sick family member at home with COVID-19 should consider postponing/rescheduling elective treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with dental treatment.COVID-19 Consent*Dear Patient: You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID - 19 pandemic. Please be advised of the following: * While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees. * Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without our knowledge. * In order to reduce the risk of spreading COVID-19, we have asked you a number of screening questions. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers. * To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. I agree to above mentioned consent.Signature of Patient or Legal Guardian*Today's Date: 11/05/2025HiddenUsernameThis is a hidden field HiddenConsent LabelThis is a hidden field HiddenConsent TextDear Patient: You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID - 19 pandemic. Please be advised of the following: * While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees. * Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without our knowledge. * In order to reduce the risk of spreading COVID-19, we have asked you a number of screening questions. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers. * To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.HiddenHide QuestionsThis is a hidden field
