Bales Wellness Screening & Treatment Consent

Name*

First NameLast Name

Patient Name (if different)

First NameLast Name

In the last 14 days, has the patient (or any member of the household) had any of the following?

Fever or above normal temperature*

YesNo

A dry cough*

YesNo

Shortness of breath or having trouble breathing*

YesNo

A runny nose*

YesNo

Have a sore throat*

YesNo

Recently lost or had a reduction in your sense of smell?*

YesNo

Persistent pain, pressure or tightness in chest*

YesNo

Has the patient, a family member, or any known close contact been diagnosed with COVID-19 infection, or any other communicable disease*

YesNo

Is the patient, a family member, or any known close contact waiting on results of test for COVID-19 infection*

YesNo

Have you traveled outside the United States by air or cruise ship inthe past 14 days?*

YesNo

If the answer is yes to any of the previous questions, I understand I will be asked to reschedule today's appointment.*

I acceptI do not accept

COVID‐19 PANDEMIC DENTAL TREATMENT NOTICE AND ACKNOWLEDGEMENT OF RISK FORM

Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community.This document provides information we ask you to acknowledge and understand regarding the COVID‐19 virus.The COVID‐19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID‐19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting COVID‐19 associated with dental care.The COVID‐19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID‐19 is challenging and complicated due to limited availability for virus testing. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office. Some Dental procedures can create water spray which is one way the disease is spread. The ultra‐fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID‐19 virus to those nearby.You cannot wear a protective mask over your mouth to prevent infection during treatment as your health care providers need access to your mouth to render care. This leaves you vulnerable to COVID‐19 transmission while receiving dental treatment. We are best to limit or eliminate aerosol procedures in our Orthodontic office during this time.

I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I further confirm I am seeking treatment for a condition that meets the emergent or urgent criteria noted above. I understand and accept the additional risk of contracting COVID‐19 from contact at this office. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here.

I consent to treatment*

YesNo

Signature

Wellness Screening and Treatment Consent