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5101 29th Ave., Meridian, MS 39305

Covid Form

Covid Form

Patient Name:

	PRE-APPOINTMENT	IN-OFFICE
	Date:	Date:
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?	YesNo	YesNo
Are you/they having shortness of breath or other difficulties breathing?	YesNo	YesNo
Do you/they have a cough?	YesNo	YesNo
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?	YesNo	YesNo
Have you/they experienced recent loss of taste or smell?	YesNo	YesNo
Are you/they 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 elective treatment.)	YesNo	YesNo
Is your/their age over 60?	YesNo	YesNo
Have you/they traveled in the past 14 days?	YesNo	YesNo

Security Measure

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing, see the list of State and Territorial Health Department Websites for your specific area's information.