The World Health Organization has characterized the COVID-19 virus, also known as “Coronavirus,” as a pandemic. Our practice wants to ensure you are aware of the risks of exposure to COVID-19 associated with receiving treatment during this pandemic.
COVID-19 is highly contagious and has a long incubation period. You or your healthcare providers may have the virus, not show symptoms and yet still be highly contagious. COVID-19 can result in a life-threatening respiratory disease in some patients. You may be exposed to COVID-19 at any time or in any place. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.
Dental procedures can create fine water spray or “aerosols” which may remain in the air for several minutes to hours. These aerosols may contain the COVID-19 virus and may create a risk of COVID-19 exposure. You cannot wear a protective mask over your mouth to reduce exposure during treatment as your healthcare providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.
To provide a safe environment for our patients and staff, this practice follows the applicable state and federal regulations and protocols for infection control, universal personal protection, and disinfection. However, due to the nature of the procedures we provide, it may not be possible to maintain social distancing between patients, doctors, and staff at all times.
Patient Acknowledgement
I acknowledge that I have read the Notice above and that I understand and accept that there is an increased risk of COVID19 exposure with treatment during the pandemic.
I understand and accept the increased risk of COVID-19 exposure with treatment at this office.
I also acknowledge that I could, or may have, exposure to COVID-19 from outside this office and unrelated to my visit here.
I have read and understand the information stated above:
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Revised May 15, 2020
This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19, also known as “Coronavirus,” pandemic.
A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that such disclosures may impact treatment decisions.
People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. These symptoms may appear 2-14 days after exposure to the virus. It is important that you disclose any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.
In-Office Screening
Yes
No
Have you or anyone in your household been in contact with someone who has tested positive for COVID-19?
Have you or any one in your household tested positive for COVID-19?
Have you or any one in your household been tested for COVID-19 and are awaiting results?
Outside church or school have you been in a crowd of 10 people or more in the past 14 days?
Have you taken any fever-reducing medications or symptom altering medications, including: ibuprofen (Advil, Motrin or other), acetaminophen (Tylenol or other), naproxen (Aleve or other), or aspirin, DayQuil or other cough and cold medicne in the last 14 days and, if yes, for what reason?
Have you experienced shortness of breath or had trouble breathing?
Do you have a cough?
Do you have a runny nose?
Do you have sore throat?
Do you have muscle pain?
Have you experienced chills or repeated shaking with chills?
Have you recently lost or had a reduction in your sense of smell?
Do you have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
I fully understand and acknowledge the above information, risks and cautions and have disclosed to my provider any other conditions in my health history. By signing this document, I acknowledge that the answers I have provided above are true and accurate.
By signing this document, I acknowledge that the answers I have provided above are true and accurate. I have provided a copy of my vaccination record to have attached to my patient file.
I understand that I will continue to undergo a temperature screening for extra precautions.
Below is for office use only:
*Guest vaccination record received or Covid-19 Screening Form must be on file to enter the building.
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