Patient Screening Form


    Patient Name:
    PRE-APPOINTMENT IN-OFFICE
    Date
    Date
    Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

    Are you/they having shortness of breath or other difficulties breathing?

    Do you/they have a cough?

    Any other flu-like symptoms, such as gastrointestinal upset. headache or fatigue?

    Have you/they experienced recent loss of taste or smell?

    Are you/they 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/their age over 60?

    Do you/they have heart disease, lung disease. kidney disease, diabetes or any auto-immune disorders?

    Have you/they traveled in the past 14 days to any regions affected by COVJO-19? (as relevant to your location)

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

    • For testing, see the list of state and territorial health department Websites for your specific area's information.

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    GentileDentalCare

    A prosthodontist is a dentist who specializes in the esthetic restoration and replacement of teeth.

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    Our staff is professional and courteous with everyone who walks through our doors. We strive to give exemplary care in our practice by communicating with our patients and agreeing on a treatment plan that best suits them aesthetically, and financially.

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