Patient Advisory and Acknowledgment

Receiving Dental Treatment During the COVID-19 Pandemic

Dear Patient:

You have presented to our office today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:

While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.
Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.

In order to reduce the risk of spreading COVID 19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.

PATIENT/RESPONSIBLE PARTY

DATE

PATIENT NAME

PLEASE ANSWER “YES” OR “NO” TO THE FOLLOWING QUESTIONS:

Are you currently awaiting the results of a COVID-19 test?

Yes

Are you in contact with any confirmed COVID-19 positive patients?

Yes

Do you have a fever or have you felt hot or feverish recently (14-21 days)?

Yes

Do you have any shortness of breath or other difficulties breathing?

Yes

Do you have a cough?

Yes

Any other flu-like symptoms, such as gastrointestinal upset, diarrhea, headache or fatigue?

Yes

Do you have sneezing, runny nose, watery eyes, and/or sinus pain/pressure that is unusual and not related to seasonal allergies?

Yes

Have you experienced recent loss of taste or smell?

Yes

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Yes

Within the last 14 days, have you travelled to any foreign country or any regions affected by COVID-19?

Yes

IF SO, WHERE?

Patient Validation:

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