Drawing of a dental implant
Peter A. Russo, D.D.S., Inc.
Robert Lacrampe D.D.S.
Periodontics and Implant Surgery
18800 Main Street, Suite #201Huntington Beach, CA 92648(714) 842-2515

COIVD-19 Office Screening Form

I, , consent to receive treatment from Peter A. Russo, DDS INC. during the COVID-19 outbreak. I understand that I need to wear a mask as directed in office. I will maintain a 6ft social distance from other patients. I understand that due to the unknowns of this virus, the number of other patients that have been in the practice and the nature of the procedures performed here, that I have an increased risk of contracting the virus by being in the practice and by receiving treatment in the practice. I understand that dental procedures have the potential to include aerosol-generating procedures as well as anticipated splashes and sprays, which are some of the ways that COVID-19 can be spread. I understand and take responsibility for the risks associated with receiving dental treatment during the COVID-19 pandemic.

Filled out by office staff
Do you have fever (>100.°F), chills or have you felt hot or feverish recently (14-21 days)?
Are you having shortness of breath or other difficulties breathing?
Do you have a dry cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Do you have a runny nose?
Do you have unexplained muscle pain?
Do you have a sore throat?
Have you experienced recent loss of taste or smell?
Do you have pain or pressure in your chest?
Have you tested for COVID-19 in the last 14 days?
If yes, what is the result of the testing?
If negative, proceed to next question.
If still waiting on results, we will need to reschedule appointment after results are known.
Have you in the past been confirmed for having COVID-19?
Are you 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 treatment.
Are you fully vaccinated for COVID-19?
Is your age over 60?
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you traveled more than 100 miles from your home in the in the past 14 days?

I agree to notify the dental practice if within 14 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 14 days.