COVID-19 Screening Form in New York, NY | Pediatric Dental Associates of Manhattan

Patient Advisory and Acknowledgment

Receiving Dental Treatment During the COVID-19 Pandemic

Dear Patient:

You have come to our offce today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:

While our offce complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.
Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.

PATIENT/RESPONSIBLE PARTY*

DATE*

ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST?*

Yes
No

DO YOU HAVE A FEVER?*

Yes
No

DO YOU HAVE ANY SHORTNESS OF BREATH?*

Yes
No

DO YOU HAVE A DRY COUGH?*

Yes
No

DO YOU HAVE A RUNNY NOSE?*

Yes
No

DO YOU HAVE A SORE THROAT?*

Yes
No

DO YOU HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURE THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES?*

Yes
No

HAVE YOU EXPERIENCED HEADACHES, FATIGUE, OR WEAKNESS?*

Yes
No

HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL?*

Yes
No

WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED TO ANY FOREIGN COUNTRY?*

Yes
No

WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED WITHIN THE UNITED STATES?*

Yes
No

IF SO, WHERE?*