Covid 19 Questionnaire Master page Dental Office Name Please enable JavaScript in your browser to complete this form. - Step 1 of 5Name *FirstLastPhone *NextDo you currently have or had any of the following in the last 30 days? *FeverChillsCoughShortness of breathSore throatNew loss of smell or tasteNone of the aboveNextHave you had a positive Covid 19 test or awaiting results? *YesNoHave you been in contact with someone who has had positive Covid 19 test? *YesNoNextHave you traveled out of country in last 30 days? *YesNoHave you been asked to self quarantine by a doctor or any public health offical? *YesNoNextBy signing below, I acknowledge the above information is true to my knowledge. Your health and safety is our top priority. We are adhering to precautions outlined by the Center for Disease Control (CDC) and the Washington State Department of Health. A weak or compromised immune system (including, but not limited to, diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19 and may result in the need to consider rescheduling treatment. At our office we continue to use Universal Precautions along with WISHA and CDC infection control protocols and standards, and we are trained to prevent the spread of infectious diseases such as the flu, HIV, hepatitis, and tuberculosis. These precautions that we take every day will also help prevent the spread of Coronavirus. The Coronavirus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. While we have taken additional precautions which enhance our safe treatment environment and further minimize the possibility of exposure, an increased possibility of transmission exists simply by being out in public, including a dental healthcare facility. *Clear SignatureWould you like a copy this form? *YesNoEmail *EmailConfirm EmailEmailSubmit
