Peninsula Dental Care Covid-19 Screening Questionnaire Name* First Last Date Of Birth* MM DD YYYY Have you been completely vaccinated for COVID-19?*YESNOPREFER NOT TO ANSWERDo you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*YESNOAre you/they having shortness of breath or other difficulties breathing?*YESNODo you/they have a cough?*YESNOAny other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*YESNOYou selected YES, Please provide more details*Have you/they experienced recent loss of taste or smell?*YESNOAre you/they in contact with any confirmed COVID-19 positive patients?*YESNOIs your/their age over 60?*YESNODo you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*YESNOHave you/they traveled in the past 14 days outside your state? (as relevant to your location)*YESNOWhere have you traveled to?*Have you been tested positive to COVID-19?*YESNOWhen did you get tested positive to COVID-19?* MM DD YYYY Have you been tested again as negative to COVID-19?*YESNOWhen did you get tested negative to COVID-19?* MM DD YYYY 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: 06/01/2023UsernameThis is a hidden field Consent TextPlease 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.HideAgeThis is a hidden field ← stapletonortho → bluehillsdmd