Alison Jackson DDS - Covid-19 Patient Screening Form
Please complete the following form before you arrive for your appointment (within 24 hrs.) Press submit when you are finished and the form will upload to our office (no paper needed.) If you have any questions please call our office at 831-662-2900.
Date of upcoming APPOINTMENT:
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Patient's first name: *
Patient's last name: *
Parent/Guardian's first and last name: *
Does your child have a fever or above-normal temperature (>100.4° F)? *
Required
Is your child experiencing shortness of breath or having trouble breathing? *
Required
Does your child have a dry cough? *
Required
Does your child have a runny nose? *
Required
Has your child recently lost or had a reduction in their sense of smell or taste? *
Required
Does your child have a sore throat? *
Required
Is your child experiencing chills or repeated shaking with chills? *
Required
Does your child have unexplained muscle pain? *
Required
Does your child have a headache? *
Required
Does your child have an upset stomach and/or diarrhea? *
Required
Even if your child doesn't currently have any of the above symptoms, have they experienced any of these symptoms in the last 14 days? *
Required
Have you, your child or anyone in your immediate family been in contact with someone who has tested positive for COVID-19 in the last 14 days? *
Required
Has your child been tested for COVID-19 in the last 14 days *
Required
If you answered yes to the question above, what is the result of the testing?
Has your child traveled more than 100 miles from your home in the last 14 days? (Please call us if you or your child has traveled by plane, train or bus, OR if you have attended a large out-of-town gathering.) *
Required
I agree to notify the dental practice if my child becomes ill with COVID-19 symptoms or tests positive for COVID-19 within 14 days of my visit. I understand the dental practice has a legal and ethical obligation to inform me if a staff person my child had contact with tests positive for COVID-19 within 14 days. *
Required
𝗣𝗮𝗿𝗲𝗻𝘁/𝗚𝘂𝗮𝗿𝗱𝗶𝗮𝗻 𝗦𝗶𝗴𝗻𝗮𝘁𝘂𝗿𝗲 - By entering your full name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *
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