COVID 19 SCREENING FORM and CONSENT FORM:
Patient Name: _______________________________________________ Date: __________________________
Have you had the Covid 19 Vaccine? If YES, 1 shot or 2 (circle) Approx. Date: _______________
Pfizer Moderna Johnson & Johnson (please check one if you had the vaccine)
Have you or anyone in your household tested positive at ANY TIME or been diagnosed as having COVID-
19? If YES, when? DATE: ________________ (approximate is fine)
Are you having shortness of breath or difficulties breathing?
Have you had a fever, felt feverish, have a cough or sore throat in the last 14-21 days?
Any other flu-like symptoms, upset stomach, GI issues, headache or fatigue? Loss of taste or smell? If yes
to any-please circle symptoms.
Have you or a member of your household traveled in the past 14 days OUTSIDE the United States?
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
If yes to any of the above-please be aware that you are at higher risk for COVID 19. __________ (patient
Thank you for your trust and confidence in our practice and team. Your health and safety are our top priority. As
with the transmission of any communicable disease (like the flu or a cold), you may be exposed to COVID-19
(Coronavirus) at any time or place. We have always followed the federal and state regulations. In addition, we have
always followed the personal protection recommendations and disinfection protocols to limit the transmission of all
diseases in our office.
Despite our very careful attention to sterilization, disinfection and use of extra personal protection barriers, there is
still a chance you could be exposed to an illness in our office, just like you could by visiting your grocery store,
pharmacy, local restaurant or gym. Although we have taken extra measures to provide social di