COVID-19 Dental Treatment Consent

knowingly and willingly consent to have {circle an option - preventive, elective, restorative, emergency} dental treatment completed during to COVID-19 pandemic.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has the virus and who does not given the current limits in testing.

Dental procedures create water spray which is how the disease is spread. The ultra fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.

I understand that due to the frequency of visits of other dental patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office.

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. The CDC recommend social distancing of at least 6 feet for a period of 14 days to anyone who has traveled by air. Social distancing is not possible during dental treatment

I verify that I have not traveled outside of the United States in the past 14 days to countries that have been affected by COVID-19

I verify that I have not traveled domestically within the United States by commercial airline, Bus, or train within the past 14 days.

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.

Signature Patient or Parent/Guardian

Date

River Forest Dental Studio COVID-19 Patient Screening Questionnaire

Patient's Name

Date

Pre - Appointment

In - Office

Post- Appointment

(Patient self-reports within 14 days after appointment, if symptoms or diagnosis of COVID-19)

Screening Questions

1. Do you have a fever, or have you felt feverish recently?

Yes No

3. Do you have a cough?

Yes No

4. Are you having shortness of breath or any difficulty breathing?

Yes No

5. Do you have chills or repeated shaking with chills?

Yes No

6. Do you have any muscle pain?

Yes No

7. Do you have any recent onset of headache or sore throat?

Yes No

8. Do you have any other flu-like symptoms?

Yes No

9. Do you have any recent loss of taste of smell?

Yes No

10. Have you experienced any recent GI upset or diarrhea?

Yes No

11. Are you in contact with anyone who has been confirmed to be COVID-19 positive?

Yes No

12. Have you been tested for COVID-19?

Yes No

If yes, what was the result?

13. Have you been diagnosed with COVID-19?

Yes No

If yes, when?

14. Are you over the age of 65?

Yes No

Do you have?

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.

Patient Signature

Date

Your information will be encrypted.