COVID-19 PATIENT SCREENING QUESTIONNAIRE

COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURE & CONSENT FOR TREATMENT

Rami F.Rizk, D.M.D.
Allendale Family and Cosmetic Dentistry
70 W Ave, Allendale Suite B
Allendale, New Jersey 07401
Tel. 201-825-9229

Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus,” at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.

Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. “Social Distancing” nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, dentist, office staff and sometimes other patients at all times.

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID‐19 virus.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk
for contracting COVID‐19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID‐19, or whether you have experienced any signs or symptoms associated with the COVID‐19 virus.

Although exposure is unlikely, By signing below you accept the risk and consent to treatment?

Please review the following self screening criteria: *

	Yes	No
Has the patient or anyone in the family (household) tested positive for COVID-19?
Has the patient or anyone in the family (household) been tested for COVID-19 and are awaiting results?
Does the patient or anyone in the family (household) have any of the following respiratory symptoms? Fever, Sore Throat, Cough, Shortness of Breath?
Has the patient or anyone in the family (household) recently lost your sense of smell or taste?
Does the patient or anyone in the family (household) have any GI symptoms? Diarrhea? Nausea?
Even if you don’t currently have any of the above symptoms, has the patient or anyone in the family (household) experienced any of these symptoms in the last 14 days?
Has the patient or anyone in the family (household) been in contact with someone who has tested positive for COVID-19 in the last 14 days?
Has the patient or anyone in the family (household) traveled outside the United States by air or cruise ship in the past 14 days?
Has the patient or anyone in the family (household) traveled within the United States by air, bus or train within the past 14 days?

If answered YES to any of the above questions, a team member of Allendale Family & Cosmetic Dentistry will reschedule you . Please contact your doctor for further advice.

If you do not meet the criteria above, please sign below indicating that you have been provided with this information.

I HAVE REVIEWED THE ABOVE CRITERIA. MY CHILD(REN) AND I DO NOT HAVE SYMPTOMS AS DESCRIBED. (Please list the full name and date of birth if the appointment for a child insert each child's information that present at today's appointment.)

Patient Name(s)/ Date of Birth:*

Legal Guardian Name:*

First NameLast Name

Relationship to Patient(s):*

Signature:*

Clear

Date:*

Date