Patient Advisory and Acknowledgment

Receiving Dental Treatment During the COVID-19 Pandemic

 

You have come 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 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.

 
 

PLEASE ANSWER “YES” OR “NO” WITH YOUR INITIALS, TO THE FOLLOWING QUESTIONS:

 

HAVE YOU BEEN TESTED FOR COVID-19 OR ANTIBODIES?

 

... AND IF SO WHAT WERE THE RESULTS?

 

DO YOU HAVE A FEVER?

 

DO YOU HAVE ANY SHORTNESS OF BREATH?

 

DO YOU HAVE A DRY COUGH?

 

DO YOU HAVE A RUNNY NOSE?

 

DO YOU HAVE A SORE THROAT?

 

DO YOU HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURE THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES?

 

HAVE YOU EXPERIENCED HEADACHES, FATIGUE, OR WEAKNESS?

 

HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL?

 

WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED TO ANY FOREIGN COUNTRY?

 

WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELED WITHIN THE UNITED STATES?