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Patient Screening Form

General Information

Patient Screening

Have you/they recently been vaccinated for COVID-19?
Have you/they recently been tested for COVID-19?
Have you/they tested positive for COVID-19?
Within the past 14 days, have you/they had a known exposure to any individual suspected or confirmed to have COVID-19 or who has traveled to a location after which self-quarantine is recommended?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
Is your/their age over 60?
Do you/they have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?

Within the past 24 hours, have you/they had any of the following symptoms?

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headaches
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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