Form: Respiratory Illness Disclosure Form

Patient Information

Dental procedures create aerosols which can linger in the air for minutes to hours and potentially transmit diseases. Because of this heightened risk, we want to protect you, our other patients, and our employees by avoiding treatment on those who have respiratory illnesses including COVID-19. 

If you answer YES to any of the following, we may respectfully request that you reschedule your appointment. 

Do you have any upper respiratory illness symptoms such as: cough, congestion, runny nose?
Do you have any cold, flu, or COVID symptoms such as: sore throat, fever, or headache?
Have you been in contact with someone who has tested POSITIVE for COVID-19?
Have you tested POSITIVE or been assumed POSITIVE for COVID-19? If yes, please enter dates of start and end of the illness

Sign Form

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.