Patient Screening Form
The questions on this form are adapted from the American Dental Association. We ask that all patients fill this out prior to their appointment and understand that the same questions will be asked upon arrival.

Positive responses to these questions does that mean the patient will not be seen, but that further discussion with Dr. Stephens will need to happen.

This is to ensure the safety of our staff and patients. If any questions or concerns arise, please call us at (479) 442-3915 or email us at

All responses to this form remain private under HIPAA regulations and information on those can be found at our website at under "Forms" or visit for more information.
Patient Name (First and Last) *
Appointment Date
1. Do you have fever or have you felt feverish in the last 14-21 days? *
2. Are you having shortness of breath or other difficulties breathing? *
3. Do you have a cough? *
4. Have you experienced any other flu-like symptoms, such as gastrointestinal pain, headaches, or fatigue? *
5. Have you experienced recent loss of taste or smell? *
6. Are you or have you been in contact with any confirmed COVID-19 positive patients? *
7. Are you 60+? *
Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders? *
Have you traveled out-of-state in the past 14 days to any regions affected by COVID-19? *
Are you waiting for the results of a COVID-19 test? *
Is there any other information you would like for us to know?
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy