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:
Date: