Virtual Check-In

Patient's Full Name

Parent or Legal Guardian's Name

Patient or Legal Guardian's Phone

Have you come in contact with anyone experiencing symptoms of COVID-19 in the last 14 days?
YesNo

Have you, or anyone with you, experienced shortness of breath in the last 14 days?
YesNo

Have you, or anyone with you, experienced chest pressure in the last 14 days?
YesNo

Have you, or anyone with you, experienced a persistent cough in the last 14 days?
YesNo

Have you, or anyone with you, had a fever in the last 14 days?
YesNo

Have you, or anyone with you, been tested for COVID-19 and are awaiting the results?
YesNo

Have you, or anyone with you, traveled within the USA by air, train, bus, or other public transportation in the last 14 days?
YesNo

Have you, or anyone with you, traveled overseas in the last fourteen (14) days?
YesNo

Have you, anyone with you, or any of your recent acquaintances tested positive for COVID-19 or any other diseases in the last 14 days?
YesNo

Does the patient have any chronic immune or systemic conditions?
YesNo

Is the patient older than 65?
YesNo

By checking this box, I acknowledge that the above information is correct and I understand it is my responsibility to inform the office of any changes in my health as soon as possible.

By checking this box, I understand the above information and agree with its contents. This will serve as my electronic signature for the Administration Form.

By checking this box, I grant my permission to Sunriver Dental Care to upload and store confidential patient information (including account information, appointment information, and clinical information) to a secured server for the dental practice. I understand the dental practice cannot and does not assume any responsibility for my use or misuse of patient information or other information transmitted, monitored, stored, uploaded or received using the site or the services.