The Bite Dental - COVID-19 Questionnaire

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Email *

Name

In the past 14 - 21 days, has the patient , their caregiver, or any close household contact traveled in the country, internationally or taken a cruise? *

YES

In the past 14 - 21 days, has the patient been in contact with any confirmed COVID-19 positive patients? *

YES

Are you or the patient experiencing a high fever ( 100.4F or greater ), dry cough or any other flu-like symptoms? *

YES

Do you or the patient have heart disease, lung disease, kidney disease, diabetes or any other auto-immune disorder *

YES

IF THE ANSWER IS YES TO ANY OF THE QUESTIONS PLEASE NOTIFY STAFF IMMEDIATELY.

It is our duty to follow all necessary protocols and guidelines to limit the transmission of any communicable diseases.

I acknowledge that all of the above information is true, promise to follow The Bite Dental's present protocol recommendation, accept the potential risk of exposure in our practice to a communicable disease, including but not limited to COVID-19, and consent to treatment? *

YES

Date *

YYYY

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