Patient Advisory and Acknowledgement Form

Receiving Dental Treatment During the COVID-19 Pandemic
Dear Patient:
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 the Centers for Disease Control andPrevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot makeany guarantees. Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients)could be infected, with or without their knowledge. In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below.For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
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PLEASE ANSWER “YES ” OR “ NO ” TO THE FOLLOWING QUESTIONS :
HAVE YOU BEEN DIAGNOSED POSITIVE FOR THE COVID-19 VIRUS AT ANY TIME?(Required)
ARE YOU CURRENTLY AWAITING THE RESULT S OF A COVID-19 TEST?(Required)
DO YOU HAVE A FEVER?(Required)
DO YOU HAVE ANY SHORTNESS OF BREATH?(Required)
DO YOU HAVE A DRY COUGH?(Required)
DO YOU HAVE A RUNNY NOSE?(Required)
DO YOU HAVE A SORE THROAT?(Required)
DO YOU HAVE SNEEZING , WATERY EYES , AND/OR SINUS PAIN / PRESSURE THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES?(Required)
HAVE YOU EXPERIENCED HEADACHES , FATIGUE , OR WEAKNESS?(Required)
HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL?(Required)
WITHIN THE LAST 14 DAYS , HAVE YOU TRAVELLED TO ANY FOREIGN COUNTRY?(Required)
WITHIN THE LAST 14 DAYS , HAVE YOU TRAVELLED WITHIN THE UNITED STATES OR TO ANY FOREIGN COUNTRY?(Required)