Form: Patient Pre-Appointment Screening Form
Patient Information
FIRST name
LAST name
MI
Date form completed
Do you have a fever, or have you felt hot or feverish recently (14-21 days)?
No
Yes
Are you having shortness of breath or other difficulties breathing?
No
Yes
Do you have a cough?
No
Yes
Any other flu-like symptoms such as gastrointestinal upset, headache, or fatigue?
No
Yes
Have you experienced recent loss of taste or smell?
No
Yes
Are you, or have you been, 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 their appointment)
No
Yes
Is your age over 60?
No
Yes
Do you have heart disease, lung disease, kidney disease, or any auto-immune disorders?
No
Yes
If yes, describe?
Have you or anyone in the household traveled outside Vermont recently?
No
Yes
If yes, where?
In the event that I am late or miss my appointment I understand I will be charged $50 for the appointment.
yes
Thank you for your cooperation and understanding; positive responses may indicate a deeper discussion with Dr. Beisiegel before proceeding with dental treatment.
Sign Form
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 responsibly to inform the dental office of any changes in medical proceeding with dental treatment.
I consent to use Electronic Records and Signatures.
yes
Relationship to patient
Select releationship
Self
Mother | Step-Mother
Father | Step-Father
Grandparent
Other
Name
