Patient Advisory & Acknowledgement

Receiving Dental Treatment During the COVID-19 Pandemic

You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:
While our office complies with State Health Department and Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.
Our staff are symptom-free and, to the best of our knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including patients) could be infected, with or without their knowledge.
In order to reduce the risk of spreading the COVID-19, we are asking all patients to complete a screening questionnaire. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.

Patient First Name (legal):
Last Name:

Has the patient, parent, or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease?

Does the patient, parent, or any other recent acquaintances have any of the following:
- A fever (defined as above 100.3° F degrees)
- A cough?
- Shortness of breath and/or trouble breathing
- Persistent pain, pressure or tightness in the chest
- Sore throat
- Loss of smell or taste
If yes, please explain?

Has the patient, parent, or other recent acquaintances travelled outside the United States by air, bus, or train within the last 14 days?

I understand that if the answer is YES to any of the above questions, I will be asked to reschedule my child’s dental/orthodontic appointment.
Patient/Parent/Guardian Signature: