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Neil L. Starr, DDS, PC

Patient Screening Form

Patient Information

First Name: *

Last Name: *

Date: *

  

1. Do you currently have (or have you experienced) any of the following symptoms in the past 21 days?

Fever *

Yes No  

If fever, how did you measure it?

Fatigue (feeling tired) *

Yes No  

Altered or loss of taste/smell *

Yes No  

Dry cough *

Yes No  

Trouble breathing *

Yes No  

Shortness of breath, difficulty *

Yes No  

Confusion *

Yes No  

Bluish lips or face *

Yes No  

Chills/repeated shaking with chills *

Yes No  

Muscle pain *

Yes No  

Headache or sore throat *

Yes No  

Any other flu-like symptoms *

Yes No  

Please list:

GI upset or diarrhea *

Yes No  

2. Are you in contact with anyone who has been sick and/or confirmed to be COVID-19-positive? *

Yes No  

3. In the past 14 days have you traveled to any regions affected by COVID-19? *

Yes No  

4. Have you previously been diagnosed with COVID-19?
(If NO to question 4, skip to question 8) *

Yes No  

5. If YES, when and how were you confirmed positive?

6. If you have had COVID-19, when were you confirmed negative?

7. If you have had COVID-19, how were you confirmed negative?

I was diagnosed negative by a nasal swab test

I show antibodies to COVID-19 with a blood test

My doctor said I no longer have it because I don't have any symptoms

I don't have any symptoms, so I don't have it

Some medical conditions have been associated with more severe COVID-19 disease. The following questions are an attempt to determine your risk

8. Are you over age 65? *

Yes No  

9. Do you have high blood pressure? *

Yes No  

If yes, is it controlled?

Yes No  

10. Do you have diabetes? *

Yes No  

11. Are you overweight? *

Yes No  

12. Do you have respiratory problems? *

Yes No  

13. Do you have any autoimmune disorders? *

Yes No  

14. Are there any other conditions you would like to report?

 

COVID-19 Liability Waiver

I acknowledge the contagious nature of the Coronavirus / COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Neil L. Starr, D.D.S., P.C. has put in place preventative measures to reduce the spread of Coronavirus / COVID-19.

I further acknowledge that Neil L. Starr, D.D.S., P.C. (hereafter the "Office") cannot guarantee that I will not become infected with Coronavirus / COVID-19. I understand that the risk of becoming exposed to and/or infected by Coronavirus / COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, the doctors, staff and other patients.

I voluntarily seek services provided by the Office and acknowledge that I am increasing my risk to exposure to Coronavirus / COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.

I attest that:

I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.

I have not traveled internationally within the last 14 days.

I have not traveled to a highly impacted area within the United States of America within the last 14 days.

I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus / COVID-19.

I hereby release and agree to hold the Office harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of actions, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the Office or that may otherwise arise in any way in connection with any services received from the Office. I understand that this release discharges the Office from any liability or claim that I, my heirs, or any personal representative may have against the Office with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from the Office. This liability waiver and release extends to the Office doctors and employees.

Full Name: *

 
 

Confirmation

 
 

Please wait, it may take a moment to submit your information.

 


Neil L. Starr, DDS, PC

Washington Office

1234 19th Street N.W. #306
Washington, DC 20036

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