James Ku, D.D.S 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.Dental treatment in the era of Covid-19*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. You could contract COVID‐19 from a variety of sources. Our practice wants to ensure you are aware of the risks of contracting COVID‐19 associated with dental care. 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 an enclosed area. All dental staff will have personal protective equipments such as masks, face shields or goggles, and gloves. Additionally we space out patients’ visits and use air purifiers to protect patients. Thank you for your continued trust in our practice. Be assured that we have always followed state and federal regulations, recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so. We continue to incorporate additional measures for your safety. I confirm that I have read the Notice above and understand and accept that there is a risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here. I have read and understand the information stated above: I agree to above mentioned consent.Signature of Patient or Legal Guardian*Today's Date: 11/23/2025HiddenUsernameThis 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. You could contract COVID‐19 from a variety of sources. Our practice wants to ensure you are aware of the risks of contracting COVID‐19 associated with dental care. 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 an enclosed area. All dental staff will have personal protective equipments such as masks, face shields or goggles, and gloves. Additionally we space out patients’ visits and use air purifiers to protect patients. Thank you for your continued trust in our practice. Be assured that we have always followed state and federal regulations, recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so. We continue to incorporate additional measures for your safety. I confirm that I have read the Notice above and understand and accept that there is a risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here. I have read and understand the information stated above:HiddenHideAgeThis is a hidden field ← Glfdgalmont → marshfamilydental
