ADA Patient Screening Form for COVID-19 Health Information
This file is a patient screening form provided by the ADA for pre-appointment and in-office health checks. It includes questions related to COVID-19 symptoms, recent travel, and contact with confirmed cases. The form is used to ensure patient and staff safety before dental treatments.
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How do I fill this out?
This form needs to be filled out by answering questions related to your health and recent activities. Make sure to provide accurate and honest answers to each question. Once completed, submit the form to your dental office either in advance or at the time of your appointment.
How to fill out the ADA Patient Screening Form for COVID-19 Health Information?
1
Answer each health-related question honestly.
2
Include any symptoms you have experienced recently.
3
Note any contact with COVID-19 positive patients.
4
Provide information about recent travel.
5
Submit the completed form to your dental office.
Who needs the ADA Patient Screening Form for COVID-19 Health Information?
1
Patients visiting a dental office need this form to ensure safety.
2
Dentists and dental staff need the form to assess patient health.
3
Health professionals use the form for pre-appointment checks.
4
Individuals with symptoms of COVID-19 use the form for reporting.
5
Travelers returning from affected areas use the form for health declarations.
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What are the instructions for submitting this form?
Submit the completed form to your dental office through one of the following methods: Email it to your dental office's provided email address. Fax it to your dental office using the provided fax number. Submit it online through your dental office's submission portal. Alternatively, bring a printed copy to your appointment. Ensure that all information is accurate and complete before submission. Our advice is to submit the form as early as possible to allow the dental office to review your information ahead of your visit.
What are the important dates for this form in 2024 and 2025?
Keep the form updated for routine check-ups in 2024 and 2025 to ensure safety during dental appointments.
What is the purpose of this form?
The purpose of the ADA Patient Screening Form is to ensure the health and safety of patients and dental staff before proceeding with dental treatments. By answering questions related to recent health status, symptoms, and potential exposure to COVID-19, patients help the dental office assess the risk and take necessary precautions. This form is a crucial step in creating a safe environment for everyone involved in dental care.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: This field captures the name of the patient filling out the form.
- 2. PRE-APPOINTMENT: Questions to be answered before the appointment to assess health status.
- 3. IN-OFFICE: Questions to be answered at the dental office to confirm health status.
- 4. Health Status Questions: Includes questions about fever, shortness of breath, cough, flu-like symptoms, loss of taste/smell, contact with COVID-19 patients, age, and underlying health conditions.
- 5. Travel History: Questions about recent travel to regions affected by COVID-19.
- 6. Submission Date: The date on which the form is filled and submitted.
What happens if I fail to submit this form?
Failure to submit this form may result in postponement of elective dental treatments.
- Elective Treatment Delays: Without this form, the dental office may delay or reschedule non-urgent treatments to ensure safety.
- Health Risks: Not submitting the form increases the risk of unintended exposure to COVID-19 for both patients and staff.
How do I know when to use this form?
- 1. Routine Check-Ups: Before regular dental visits to ensure the patient is healthy.
- 2. Dental Treatments: Before undergoing elective dental procedures.
- 3. Symptomatic Patients: For patients experiencing any COVID-19 symptoms.
- 4. Recent Travel: For patients who have recently traveled to affected regions.
- 5. Post-COVID Contact: For patients who have been in contact with confirmed COVID-19 cases.
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What information do I need to fill out this form?
You need to provide information related to your health, recent symptoms, travel history, and contact with COVID-19 positive individuals.
Is this form mandatory for dental appointments?
Yes, it helps in assessing patient health and safety before proceeding with dental treatments.
How do I submit the completed form?
Submit the completed form to your dental office either in advance or at the time of your appointment.
Can I edit my answers after submitting the form?
You can edit your form on PrintFriendly before submitting it. Once submitted, any changes should be communicated to your dental office.
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