COVID-19 Patient Screening Form

Patient Name:
Phone Number:
Email Address:
Pre-Appointment In-Office
Date: Date:
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Yes No
Yes      No
Are you/they having shortness of breath or other difficulties breathing?
Yes No
Yes      No
Do you/they have a cough?
Yes No
Yes      No
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Yes No
Yes      No
Have you/they experienced recent loss of taste or smell?
Yes No
Yes      No
Are you/they in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective tretment.
Yes No
Yes      No
Is your/their age over 60?
Yes No
Yes      No
Do you/they have heart disease, lung disease, kidney disease,diabetes or any auto-immune disorders?
Yes No
Yes      No
Have you/they traveled in the past 14 days to any regions affected by COVID19? (as relevant to your location)
Yes No
Yes      No

Positive responses to any of these would likely indicate a deeper discussion with the dentist before with elective dental treatment.

For testing, see the list of state and Territorial Health Department Websites for your specific area's information.

Medical History Update:

Have you seen a Doctor since your last visit?
Have you been diagnosed with anything new?
Have you had any surgeries since your last visit?
Are you taking any new medications since your last visit?
Please list all medicines, including any over-the-counter, vitamins and/or supplements.
Do you have any dental concerns at this time? Broken tooth? Tooth ache?

dental dental dental
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General Dentistry
Our general dentistry services are the foundation of your oral health. At Balboa Dentistry, we offer comprehensive exams, cleanings, and preventive care to keep your teeth and gums healthy. Regular check-ups are essential in detecting early signs of dental issues and addressing them promptly. Our experienced team is committed to educating you on proper oral hygiene practices and providing personalized care tailored to your needs.

Cosmetic Dentistry
Your smile is one of your most valuable assets, and we are here to help you achieve the smile of your dreams. Our cosmetic dentistry services include teeth whitening, veneers, and smile makeovers. Whether you are looking to correct minor imperfections or undergo a complete transformation, our skilled cosmetic dentists will work with you to create a treatment plan that enhances your natural beauty and boosts your confidence.

For those seeking a straighter smile without the hassle of traditional braces, Invisalign offers a discreet and comfortable solution. Balboa Dentistry is proud to provide Invisalign treatments that fit seamlessly into your lifestyle. Using clear, removable aligners, Invisalign gradually moves your teeth into their desired position. Our team will guide you through the process, ensuring you achieve optimal results with minimal disruption to your daily life.

Dental Implants
Missing teeth can affect both your oral health and self-esteem. Dental implants are a reliable and long-lasting solution for replacing missing teeth. At Balboa Dentistry, we use advanced implant technology to restore your smile and improve your ability to chew and speak comfortably. Our dental implant specialists will work closely with you to develop a personalized treatment plan that meets your needs and ensures a natural-looking, functional result.

Experience the difference at Balboa Dentistry, where your oral health and satisfaction are our top priorities. Contact us today to schedule an appointment and take the first step toward a healthier, more beautiful smile.

Call 24/7   858-277-5141

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