Drs Dimock Weinberg and Cherry - Wilmington-ADA COVID Patient Screening Form

ADA COVID Patient Screening Form Patient Details

First Name*

Last Name*

Date Of Birth*

Address*

City*

State*

Zip*

Gender*

Family Status*

Email for confirmations*

Cell Phone # for confirmations*

ADA COVID Patient Screening Form ADA COVID Patient Screening Form

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.

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.

You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:

While our office complies with State Heatlh Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

Our staff are symptom-free and, to the best of our knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without our knowledge.

Please list all current medications, medical conditions, and allergies.

IF YOUR CHILD IS DUE CAN XRAYS BE TAKEN?*

IS YOUR CHILD UP TO DATE ON VACCINATIONS?*

I understand that the information I have given is, to the best of my knowledge, correct and that it will be held in the strictest of confidence. Because my child is a minor, it is necessary that signed permission is obtained for a parent or legal guardian before any dental services can be rendered. I understand that during my childs visit, I must remain at the office until my child is dismissed unless the office has made arrangements with my family. I give my consent to Dr. Dimock, Dr. Weinberg, Dr. Cherry, and their staff to perform such treatment, services, medication, behavior management techniques, local anesthesia or analgesia to treat any dental/oral deficiency, abnormality and/or infection.

Parent/Guardian Name (First and Last)*

Relationship to Patient*

SIGNATURE (Parent/Guardian Signature)*

(Please click below to draw/upload sign)

(Your IP Address :IP:3.239.40.250 )

ADA COVID Patient Screening Form Patient Details

ADA COVID Patient Screening Form ADA COVID Patient Screening Form

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