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.

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