COVID-19 Screening Form

Please complete the PRE-APPOINTMENT screening questions and consent below at least one day prior to your appointment. Please complete one form per scheduled patient.

COVID-19 Screening Form
Do you have a fever or have you felt hot or feverish in the last 14-21 days?
Are you having shortness of breath or difficulties breathing?
Do you have any new symptoms?
Do you have any flu-like symptoms?
Have you experienced a recent loss of taste or smell?
Have you been in contact with any confirmed COVID-19 positive patients? (Patients that are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment)
Do you have any new health concerns such as heart, lung or autoimmune disorders?
Have you traveled to any COVID-19 hot spots in the last 14 days?
Have you tested positive for covid-19 in the last 4 weeks or are you currently waiting for test results?
Consent to treatment
You understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. Hillside Dental Associates has always made patient safety a top priority. We continue to follow state and federal regulations and the recommended universal personal protection and disinfection protocols to reduce the risk of transmission of any diseases in our office. There are several modes of transmission of COVID-19 which could be present in a dental office. Hillside Dental Associates is following the ADA and CDC guidelines to minimize the risk of transmission. Despite our close attention to sterilization and disinfection you understand that due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that you have an elevated risk of contracting the virus simply by being in a dental office. The CDC recommends social distancing of at least 6 feet. Hillside Dental Associates is committed to taking all reasonable measures to allow for social distancing in our office, however, due to the treatment you are receiving it is impossible to maintain this distance at all times between the dentists, dental team members and sometimes other patients. By checking this box, you acknowledge that you have answered the above screening questions honestly and you knowingly and willingly consent to have dental treatment completed at Hillside Dental Associates during the COVID-19 pandemic.