Bright Smiles Patient Screening Form
In order to protect the health and safety of all patients and employees and at the recommendation of the ADA and CDC, we require the following form to be filled out before you visit the office. You’ll be asked the same questions again when you are in the office and your temperature will be taken. We thank you for your patience during this time. We are truly sorry for the inconvenience, but we hope you can understand the importance of limiting the spread of the virus.
Patient Name *
Do they have a fever or have you/they felt hot or feverish recently (14-21 days)? *
Are they having shortness of breath or other difficulties breathing? *
Do they have a cough? *
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *
Have they experienced recent loss of taste or smell? *
Are 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.) *
As their parent/guardian, are you over the age of 60? *
Do they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? *
Have they traveled in the past 14 days to any regions affected by COVID-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. If you're uncomfortable submitting the form online, please give us a call and we will conduct it over the phone.

For more information and testing, see the list of State and Territorial Health Department Websites for your specific area's information. www.cdc.gov/coronavirus/2019-ncov/index.html
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