COVID-19 Patient Screening Form

Please correct the errors described below.

Patient Advisory and Acknowledgement Receiving Dental Treatment during the COVID-19 Pandemic

Dear Patient:
You have presented to the office today because you have an urgent dental condition that must be treated at this time and cannot be postponed until the current COVID-19 risk period abates. Please be advised of the following:
While our office complies with the State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.

Our staffs 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.

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.

Your information will be encrypted.

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