Patient Screening Form
Please fill out the following form a week before your dental appointment or it may need to be rescheduled.
Please type your full name. *
What date and time is your next appointment? *
Has your dental insurance recently changed?
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If your insurance info has changed please provide new info below and allow us to make a copy of your card. *
Do you or anyone you have been around have/had a fever or have felt hot/feverish in the last 14/21 days? *
Are you having shortness of breath or difficulties breathing? *
Do you have a NEW dry cough or sore throat that is not caused by allergies? *
Any other flu-like symptoms such as gastrointestinal upset, headache, or fatigue? *
Have you experienced recent loss of taste or smell? *
Have you been in contact with any confirmed COVID-19 cases within the last 21 days? *
Have you been in contact with anyone awaiting a COVID-19 test or being quarantined.
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Have you been diagnosed with COVID-19? *
If diagnosed, have you tested negative with follow-up testing? *
Have you personally or have you been around anyone that has traveled outside of our country in the last 21 days? *
Have you traveled anywhere for leisure or work or been in groups more than 25? *
If yes to question above please explain!
Are you over the age of 60 with underlying health conditions such as heart disease, lung disease, kidney disease, asthma, diabetes, an auto-immune disease, or cancer? *
I understand when I get to Stanford Dental, I will wait inside my car and call 636-256-3559 upon my arrival. *
I understand my temperature must be taken upon arrival (any temp. over 100 degrees will be rescheduled) and I will be asked to wash my hands before being taken directly back to the clinical room. *
Required
I understand that I must limit, to the best of my ability, those who come with me to my dental appointment. (Our waiting room will be temporarily closed) *
I understand that if I develop any of the symptoms above before my dental appointment, I will call to reschedule immediately. *
Please submit below. If you have any questions, don't hesitate to reach out to us at 636-256-3559. If these symptoms change after filling this out please give us a call. We look forward to seeing you!
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