To the best of my knowledge, all of the preceding answers are true and correct. If there is ever any change in my child’s health or if my child’s medicines change, I will inform the doctor of dentistry at the next appointment without fail.
I hereby acknowledge and understand that there may be an increased risk that COVID-19 may be transmitted in any place of public accommodation, which includes my dentist’s office. I have been informed by my dentist of their desire to protect their patients, staff, and the community at large.
I agree to notify the dental practice if within 14 days I or my child becomes ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days.