In Office Check-In for Healthy Teeth Dental Care

Name *

First

Last

Phone *

Do you currently have or had any of the following in the last 30 days? *

Fever
Chills
Cough
Shortness of breath
Sore throat
New loss of smell or taste
None of the above

Do you still have the symptoms you checked above? *

When was the LAST TIME you had symptoms? *

Less than 10 days ago
More than 10 days ago

Have you had a positive Covid 19 test or awaiting results? *

Are you waiting covid-19 test result? *

Enter the date you were tested *

How long has it been since you were diagnosed with Covid-19? *

Less than 14 days
More than 14 days

Have you been in contact with someone who has had positive Covid 19 test? *

When was your last contact with this person? *

Less than 14 days ago
More than 14 days ago
Ongoing contact

Is this person, your *

Immediate family member
Co-worker
Other (provide detail next)

Other: *

Have you traveled out of state in last 14 days? *

Name of the state you traveled to? *

Have you been asked to self quarantine by a doctor or any public health offical? *

Why were you asked to quarantine? (select all that apply) *

Due to my existing health condition
Exposure to someone diagnosed with covid-19
I will inform you over the phone

By 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. *