Patient Advisory and Acknowledgment

You are coming to our office today for a 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 NAME *

ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST? *

YES NO

DO YOU HAVE A FEVER? *

YES NO

DO YOU HAVE ANY SHORTNESS OF BREATH THAT STARTED RECENTLY? *

YES NO

DO YOU HAVE A DRY COUGH THAT STARTED RECENTLY? *

YES NO

DO YOU HAVE A RUNNY NOSE THAT STARTED RECENTLY? *

YES NO

DO YOU HAVE A SORE THROAT? *

YES NO

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

YES NO

DO YOU HAVE HEADACHES, FATIGUE, OR WEAKNESS THAT STARTED RECENTLY? *

YES NO

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

YES NO

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

YES NO

IF SO, WHERE?

Signature *

Clear

DATE

Date

Patient Advisory and Acknowledgment

Receiving Dental Treatment During the COVID-19 Pandemic