Dental Office COVID-19 Prescreening Form

Run a quick symptom-and-exposure questionnaire before a patient steps into the dental office.

Use this template

Name

Nombre

Apellido

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Primary Phone Number

Alternate Phone Number

Email

These questions must be answered honestly under penalty of law. An answer of YES does not exclude you from treatment. Please answer YES or NO to each of the following questions:

Explain any YES answers in the box below:

Signature: By typing your name in the box below, you acknowledge that your answers you provided are true and accurate to the best of your knowledge:

Sign here

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Dental Office COVID-19 Prescreening Form

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