COVID-19

Please read, fill and sign these forms PRIOR to your appointment. The forms will be securely sent to our office and evaluated. On the day of your appointment, we will print this form, ask you the Pre-Screening questions again in case something has changed, take and document your temperature. If you have any questions or concerns, please feel free to call our office at (702)-220-5000.

Date Online Form Was Submitted: *

Date

Patient Name *

First Name Last Name

We understand that this is a difficult time for all and we, at the Dental Implant Institute, would like our patients to know that we are keeping our spirits high, maintaining and practicing good hygiene, and staying focused on providing the best care to our patients. We thank you for showing patience during this time. We are still open and are welcoming patients in need of EMERGENCY and PREVENTATIVE treatment and care. Please be prepared for some new office procedures such as temperature taking, social distancing and hand washing / mouth rinsing before seeing the dentist.

By sigining below I, {name} , consent to receive urgent/preventative care treatment from The Dental Implant Institute during the COVID-19 outbreak.
I understand there is much to learn about the newly emerged COVID-19 including how it spreads and transmitted.
I understand that based on what is currently known about COVID-19 the spread is thought to occur mostly from person-to-person via respiratory droplets among close contacts. I understand that close contact can occur from being within approximately 6 feet of someone with COVID-19 for a prolonged period of time or by having direct contact with infectious secretions from someone with COVID-19.
I understand that carriers of COVID-19 may not show symptoms but may still be highly contagious.
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 under the CDC guidelines, do not recommend proceeding with any treatment that is non-essential at this time.
I understand that the treatment I am receiving is urgent and/or necessary because of the underlying infection, pain, or conditions that limit my normal day-to-day activities. I confirm I am seeking treatment for a condition that meets these criteria.
I understand that surgical 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 that the symptoms listed below are representative of COVID-19
- Fever
- Dry Cough
- Shortness of Breath
- Increased Temperature
- Persistant pain or pressure in the chest
- Bluish lips of face
I confirm that I do not display or currently have any of the symptoms that are representative of COVID- 19, which are outlined above.
I understand that all travelers arriving from a country or region with widespread ongoing transmission, as outlined by the CDC, should stay home for 14 days to practice social distancing and monitor their health after their arrival.
I confirm that I have not traveled to any of the countries or regions with widespread ongoing transmission (Level 3 Travel Health Notice) in the past 14 days.
I confirm, to the best of my knowledge, that I have not had close contact with an individual diagnosed with COVID-19 in the past 14 days.

Signature *

Clear

Please fill this PRE-APPOINTMENT Screening Form out PRIOR to your actual appointment. Positive responses to any of these questions will require a further discussion with the dentist or your primary doctor before proceeding with treatment.

Date Online Form Was Submitted: {todaysDate}

Patient Name: {name}

Have you/they tested positive for COVID-19 in the last 14 days? *

Yes No

Are you/they currently waiting on COVID-19 test results? *

Yes No

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

Yes No

Are you/they having shortness of breath or other difficulties breathing? *

Yes No

Do you/they have a cough? *

Yes No

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

Yes No

Have you/they experienced recent loss of taste or smell? *

Yes No

Are you/they 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. *

Yes No

Is your/their age over 60? *

Yes No

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

Yes No

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) *

Yes No

Signature *

Clear

This part of the form should only be filled out and signed when you arrive at the office for your appointment. After you securely submit this form and on the day of your In-Office appointment, a staff member will print it, take and document your temperature and ask you the screening questions again in case anything has changed.

Patient Name: {name}

In-Office Appointment Date:

In-Office Patient Temperature:

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

YES NO

Are you/they having shortness of breath or other difficulties breathing?

YES NO

Do you/they have a cough?

YES NO

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

YES NO

Have you/they experienced recent loss of taste or smell?

YES NO

Are you/they 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.

YES NO

Is your/their age over 60?

YES NO

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

YES NO

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

YES NO

Patient Signature:______________________________

Please verify that you are human *

COVID-19 Patient Consent / Pre-Screening Forms

COVID-19 Patient Consent Form

PRE-APPOINTMENT Patient Screening Form

IN-OFFICE Patient Screening Form