SUPPLEMENTAL HEALTH QUESTIONNAIRE

If you have been exposed to a communicable disease, you may spread the disease to the Dentist, dental staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

Patient Name *

First

Last

Although exposure is unlikely, do you accept the risk and consent to treatment? *

Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease? *

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

Do you/they have a cough? *

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

Persistent Pain, Pressure, or Tightness in the Chest? *

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.

Is your/their age over 60? *

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.

Date *

By checking this box you indicate that you have read and agree to the Terms of Use of Dental Boost *

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This document may be in the form of an Electronic Record and may be executed using Electronic Signatures and shall be considered an original and shall have the same legal effect, validity and enforceability as a paper record. For purposes hereof, “Electronic Record” and “Electronic Signature” shall have the meanings assigned to them, respectively, by 15 USC Section 7006, as it may be amended from time to time.

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SUPPLEMENTAL HEALTH QUESTIONNAIRE

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