peninsuladentcare

Name*

First Last

Date Of Birth*

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?*

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

YES
NO

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

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.

Treatment Consent*

Please be assured that our office has always met or exceeded the requirements set forth for infection control from the CDC and OSHA, and will continue to do so. However, it is possible to contract COVID-19 infection (or any other communicable disease) in any public place. Our office has added a number of new equipment and protocols to ensure continued safety. Signing below indicates that you consent to treatment and accept the risks involved.

I agree to above mentioned consent.

Signature of Patient or Legal Guardian*

Today's Date: 05/17/2025

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Peninsula Dental Care