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Patient Screening Form

General Information

Patient Screening

Have you recently been tested for COVID-19?
Have you tested positive for COVID-19?
Do you have fever or have you felt hot or feverish recently (14-21 days)?
Are you having shortness of breath or other difficulties breathing?
Do you have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you experienced recent loss of taste or smell?
Are you 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.
Is your age over 60?
Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?
Have you traveled in the past 14 days to any regions affected by COVID-19?
(as relevant to your location)


NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.