DFW Implant Team: COVID

Patient (or companion) Name*

First NameLast Name

Birth Date*

MonthDayYear

The Center for Disease Control (CDC) has made recommendations in response to the Coronavirus Disease 2019 (COVID-19) outbreak. COVID-19 causes respiratory illnesses ranging from the common cold to severe respiratory distress.
In order to protect you and others, we are asking about symptoms and exposure to COVID-19. Your health and safety is our priority. In addition to continuously disinfecting the office, we have added hospital grade air purifiers for removal of viruses, bacteria and other contaminants for your safety. Your cooperation in filling out the following questionnaire is yet another layer of diligence to protect everyone.

Thank you for you doing your part - Dr. Donald J. Steinberg

It is important to disclose any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with COVID-19.

Please answer the following questions:*

	Yes	No
Do you have or have you had a fever or above normal temperature the last 14 days?
Have you experienced shortness of breath or trouble breathing?
Do you have a dry cough?
Do you have a runny nose?
Have you been in contact with anyone that has had a fever, runny nose, sore throat, cough, difficulty breathing or exposed to COVID-19?
Have you recently lost or had a reduction in sense of smell or taste?
Have you been in contact with someone who has tested positive for COVID-19?
Have you tested positive for COVID -19?
Have you been tested for COVID-19?
Have you traveled outside the United States by air or cruise ship in the last 14 days?
Have you traveled within the United States by air, bus or train within the past 14 days?

Will you come to your appointment alone?

YesNo

I am unable to come alone and my companion is
Significant other :   First Name   Last Name
Sibling :   First Name   Last Name
Friend :   First Name   Last Name
Neighbor/Church member:   First Name   Last Name

If you are bringing a companion to your upcoming appointment, you must have your companion complete this questionnaire as well.

Visitor Policy: Our practice does not allow visitors access to operatories in order to maintain the highest levels of safety and privacy for all patients, staff and doctor.

I fully understand and acknowledge the above information, risk and cautions regarding an office visit and have disclosed to my provider any conditions in my health history and any activities relating to increased risk to COVID-19.

By signing this document, I acknowledge the answers I have provided above are true and accurate.

Signature*

Date*

Date

We at DFW Implant Team are closely monitoring the evolving situation with COVID-19 and, as health professionals, we are making every effort to stop the spread of this virus. For your safety, we are following the most current guidelines ordered and strongly recommended by the CDC and by the state and local authorities. 

 
In our commitment to the health and safety of our patients and our team, Dr. Steinberg/DFW Implant Team comply with the state recommendations.

I, First Name* Last Name* , am aware that Dr. Steinberg and DFW Implant Team staff have taken necessary procedures recommended by the Texas Dental Association and local authorities.

The health and safety of our patients and team is our top priority.
We are all in this together.
We sincerely care about each of you and we appreciate your understanding during this

time of uncertainty.  

 
Be safe and stay well.  
 
Dr. Donald J Steinberg/DFW Implant Team

COVID-19 PANDEMIC - PATIENT DISCLOSURES

COVID-19 PATIENT RELEASE