Screening questions
Date:
Staff initial:
Notes
Patient signature required at appointment:
I agree to notify the dental practice if within 2 days I become ill with COVID-19 symptoms or test positive for COVID-19.
I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 2 days.Acepto dar aviso a la clínica dental si dentro de dos días presento síntomas de COVID-19 o tengo un resultado positivo de COVID-19. Entiendo que la clínica dental tiene la obligación legal y ética de informarme si un miembro del personal con el que tuve contacto ha tenido un resultado positivo de COVID-19 dentro de dos días.