portjeffsmiles

Name*

First Last

Date Of Birth*

MM

DD

YYYY

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?*

MM

DD

YYYY

Have you been tested again as negative to COVID-19?*

YES
NO

When did you get tested negative to COVID-19?*

MM

DD

YYYY

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: 04/25/2024

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Consent Text

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.

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Port Jefferson Smiles

CORONA VIRUS SCREENING QUESTIONNAIRE