Covid 19 Pre Screening Form

Please complete this pre‑screening form within 24 hours of your virtual appointment. Your responses help us protect patient and staff safety.

1. Patient Identification

Full Name

Date of Birth

Appointment Date

Appointment Time

Preferred Contact (Phone/Email)

3. Close Contact & Exposure

In the past 14 days, have you been in close contact (within 6 feet for ≥15 minutes or direct physical contact) with anyone confirmed or suspected to have COVID‑19?

Yes No

Had close contact with anyone who has traveled internationally or to a high‑risk area and is symptomatic?

Yes No

If yes to either, please provide date(s) and context

4. COVID‑19 Testing & Diagnosis

Have you been tested for COVID‑19 in the past 30 days?

Yes No

If yes: Test date

Result

Positive Negative Pending

Have you ever tested positive for COVID‑19?

Yes No

If yes: Date of positive test

Date of symptom resolution

5. Vaccination Status

Yes, fully vaccinated (completed primary series) Yes, partially vaccinated (only 1 of 2 doses) No

Vaccine type (if vaccinated)

Pfizer‑BioNTech Moderna Johnson & Johnson Other

Date(s) of vaccination

6. Travel History (past 14 days)

Have you traveled outside New York State or to any area with a high rate of COVID‑19 transmission?

Yes No

If yes: List location(s) and dates of travel

7. Current Health & Medications

Do you have any chronic medical conditions that may increase COVID‑19 risk?

List current medications

8. Consent & Acknowledgment

By signing below, I confirm that the information I have provided is accurate and complete to the best of my knowledge. I understand that withholding or providing false information may put others at risk and jeopardize my ability to receive dental care at Your Smile Partners PLLC.

I agree to notify the practice immediately if my health status changes before my scheduled appointment.

I agree to the above statements.

Patient Signature

Date

If signed by guardian/representative

Name

Relationship

Representative Signature

Date

Thank you for helping us maintain a safe environment for all. If you develop new symptoms or have questions, please contact us immediately at talk@yoursmilepartners.com or (212) 555‑SMILE.

Teledentistry COVID-19 Pre‑Screening Form

1. Patient Identification

2. Recent Symptoms (within the past 14 days)

3. Close Contact & Exposure

4. COVID‑19 Testing & Diagnosis

5. Vaccination Status

6. Travel History (past 14 days)

7. Current Health & Medications

8. Consent & Acknowledgment

If signed by guardian/representative