Patient Screening Form - Bowery Dental

Bowery Dental - Patient Screening Form

Patient Name *

Have you been fully vaccinated against COVID-19? *

Within the last 3 weeks, 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 elective treatment.

Within the last 3 weeks, have you traveled to any regions severely affected by COVID-19? *

Do you have a fever or have you felt hot recently (14-21 days)? *

Are you having difficulties breathing, coughing, or experiencing a loss of taste or smell? *

Date *

Patient Signature *

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

Phone