COVID 19 Treatment Screening

Based on CDC recommendation and from the CDC website:

“The patient should be asked about the presence of symptoms of a respiratory infection and history of travel to areas experiencing transmission of COVID-19 or contact with possible patients with COVID-19. If the patient is afebrile (temperature < 100.4˚F) and otherwise without symptoms consistent with COVID-19, then emergency dental care may be provided using appropriate engineering controls, work practices, and infection control practices.”

  • DD slash MM slash YYYY
  • In the past few days have you experienced any of the following?
  • I certify that the above information given to my health care provider is accurate and true.
  • Max. file size: 80 MB.