Patient Questionnaire to fill in upon arrival

PATIENT QUESTIONNAIRE:                                              PATIENT TEMPERATURE: ______

  1. Have you traveled by airplane in the last 3 weeks?   _____________________________
  • Have you been in contact with anyone who was sick? ___________________________
  • Have you attended any large group functions? ­­­­­­­­­­­­­­_________________________________
  • Have you had any of the following symptoms within the last two weeks: fever, fatigue, dry cough, altered taste, altered smell, trouble breathing, productive cough (mucous in cough), or muscle pain?


  • Have you previously had the SARS-COV-2 Virus (novel coronavirus)? If so, did you test positive and what test were you administered?


  • Are you over the age of 65 and/or have pre-existing health conditions related to the following: diabetes, chronic lung disease or asthma, serious heart condition, immunocompromised, or chronic kidney or liver disease?


Koren Family Dental is following over and above CDC, ADA and NJDA recommendations for infection control.

This form is an acknowledgement that even with following all these guidelines, there is still a risk with treatment due to aerosols and close contact.

Dr. Koren has the right not to treat due to your answers and within his professional opinion that you may be a higher risk patient.

I agree to be treated knowing all the above.

_______________________________________________  __________________________

Patient (or Guardian) Signature                                              Date

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