Great Lakes Dental Excellence-ADA COVID Patient Screening Form

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5978 Harvey St Muskegon, MI 49444, (231) 799-0404

ADA COVID Patient Screening Form Patient Details

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First Name*

Last Name*

Middle Name

Date Of Birth*

Address*

City*

State*

Zip*

Gender*

Marital Status*

Social Security Number*

Driving License Number

ADA COVID Patient Screening Form Contact Information

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Email*

Home Phone Number

Cell Phone Number*

Work Phone Number

Work Extension Number

ADA COVID Patient Screening Form ADA COVID Patient Screening Form

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

Are you/they having shortness of breath or other difficulties breathing?

Do you/they have a cough?

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

Have you/they experienced recent loss of taste or smell?

Are you/they 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.

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

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

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.

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