Covid-19 consent and questionnaire
Even after following protocols set by the American Dental Association and our state’s dental association, it is still possible to contract COVID-19 while at a dental office. We are following all guidelines to minimize the risk of transmission.    
Sign in to Google to save your progress. Learn more
Email *
1. Appointment Date *
2. Patient First Name *
3. Patient Last Name *
4. Guardian First Name
5. Guardian Last Name
6. Relationship to the Patient *
7. Cell phone # *
8. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. I understand that the COVID-19 virus has a long incubation period during which carriers of this virus may not show symptoms and may still be highly contagious. *
9. I understand that – due to the frequency of visits of other dental patients, the characteristics of the COVID-19 virus, and the characteristics of dental procedures – I have an elevated risk of contracting the COVID-19 virus simply by being in a dental office. *
10. I confirm that I am not presenting any of these COVID-19 symptoms: Fever(100.4° F degrees), Shortness of breath, Dry cough, Runny nose, Sore throat *
11. If you have above symptoms, do you have symptoms in past 14 days?
Clear selection
12. Have you had the COVID virus within past 14 days? *
13. Have you been around any individual who has had these symptoms or tested positive for COVID-19 within past 14 days? *
14. If yes, do you get tested for antibody or Corona virus?
Clear selection
15. I confirm that I have not been in contact with a person who has been diagnosed with COVID-19 within the past 14 days. *
16. If you have been in contact with a person who has been diagnosed with Covid-19 for past 14 days, do you get tested for antibody or Corona virus?
Clear selection
17. I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. And the CDC recommends social distancing of at least six feet for a period of 14 days to anyone who has recently traveled, and this is not possible with dentistry. *
18. Have you or others accompanying you to today’s appointment traveled outside of our local area or outside of the US within the past 14 days? *
19. If yes, please confirm you have no symptoms or get tested for antibody or was tested positive and free of Corona virus for past 14 days.
Clear selection
21. Have you been vaccinated for Covid-19?
Clear selection
How many doses?
Clear selection
20. Note to the office
Patient/Guardian Signature *
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy