Document

Lehigh Valley Cosmetic Dentistry

Your Smile is in Safe Hands

ADA Covid Screening

Patient Name

Phone Number

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
For testing, see the list of State and Territorial Health Department Websites for your specific area's information.

Do you have a fever or have you felt hot or feverish recently
(14-21 days) ?

Yes

Are you having shortness of breath or other difficulties breathing ?

Yes

Do you have a cough ?

Yes

Any other flu-like symptoms, such as gastrointestinal upset,
headache or fatigue ?

Yes

Have you experienced recent loss of taste or smell ?

Yes

Are you in contact with any confirmed COVID-19 positive patients?
(Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment).

Yes

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders ?

Yes

Have you traveled in the past 14 days to any regions affected by COVID-19 ?

Yes

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 consent to use Electronic Records and Signatures (Read Electronic Record and Signature Disclosure).

Signature

Date