www.drnathan.com/COVID-19 screening and dental treatment consent form

COVID-19 screening and dental treatment consent form
Patient Name *

First Name Middle Name Last Name
*

I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:
- FEVER (feeling hot to touch, a temperature of 100 degrees Fahrenheit or higher)
- CHILLS
- COUGH that's new or worsening (continuous, more than usual)
- BARKING COUGH, making a whistling noise when breathing ('CROUP')
- SHORTNESS OF BREATH (out of breath, unable to breathe deeply)
- SORE THROAT
- DIFFICULTY SWALLOWING
- RUNNY NOSE (not related to seasonal allergies or other know causes or conditions)
- NASAL CONGESTION (not related to seasonal allergies or other known causes or conditions)
- LOSS OF SENSE OF SMELL
- PINK EYE (conjunctivitis)
- HEADACHE that's unusual or long-lasting
- DIGESTIVE ISSUES (nausea/vomiting, diarrhea, stomach pain)
- MUSCLE ACHES
- EXTREME TIREDNESS THAT IS UNUSUAL (fatigue, lack of energy)
- FALLING DOWN MORE THAN USUAL
- FOR YOUNG CHILDREN & INFANTS: Sluggishness or lack of appetite
*

I verify that I have not traveled outside of United States in the past 14 days and have not been in touch with anyone with covid/potential covid in the last 14 days.
*

I, knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.
Thank you for doing your part in keeping everyone safe. Please note the following:
- wear a MASK when entering the dental office
- SANITIZE your hands immediately upon arrival
- maintain Social Distancing from other patients
- have your Temperature taken by our team members
- not have any Accompaniment except small child/caregivers/translators
Signature *
Date *

Month Day Year
Date
Should be Empty: