Pre-Appointment Screening Form

Required fields *

ALL fields are strongly encouraged

Full Legal Name

Date of Birth

Your health is important to us. In order to provide excellent care with safety, it is necessary to become acquainted with vital information related to each patient. Thus, it is extremely important that you answer the following questions as accurately as possible. If you have any questions regarding the information requested, please feel free to ask the doctor or a member of the staff for assistance.

Do you have a fever, or have you felt hot or feverish recently (14-21 days)?

Yes

Are you having shortness of breath or other difficulties breathing?

Yes

Do you have a cough?

Yes

Any other flu-like symptoms such as gastrointestinal upset, headache, or fatigue?

Yes

Have you experienced recent loss of taste or smell?

Yes

Are you, or have you been, in contact with any confirmed COVID-19 positive patients? (patients who are well but who have a sick family member at home with COVID-19 should consider postponing their appointment)

Yes

Is your age over 60?

Yes

Do you have heart disease, lung disease, kidney disease, or any auto-immune disorders?

Yes

If yes, describe?

Have you or anyone in the household traveled outside Vermont recently?

Yes

If yes, where?

In the event that I am late or miss my appointment I understand I will be charged $50 for the appointment.

Yes

Thank you for your cooperation and understanding; positive responses may indicate a deeper discussion with Dr. Beisiegel before proceeding with dental treatment.

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 responsibly to inform the dental office of any changes in medical proceeding with dental treatment.

I consent to use Electronic Records and Signatures.

Yes

Signature

Date

Printed Name

Relationship to Patient