COVID-19 Patient Notice and Acknowledgement Form

Please correct the errors described below.

Do you currently have or had any of the following symptoms of COVID-19 in the last 14 days:

(This list is not all possible symptoms. CDC will continue to update the list as we learn more about COVID-19.)

I understand that due to the frequency of other patients being seen and the nature of the COVID-19 virus being an airborne virus, there is an increased level of risk by being in a dental office. I understand the CDC recommends social distancing of six feet and this is not possible in dentistry. I have been informed of the preventive steps and safety protocols that are in place to protect myself, dental employees and the doctor while being seen for treatment.

I am comfortable with the information that has been provided. I understand that I have the option of delaying treatment and I am knowingly and willingly electing to proceed with treatment at this time.

I agree to notify the dental practice if within 2 days I developed COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 2 days.

If you developed COVID-19 symptoms, or have been in contact with someone who does after you filled out this form, please contact us to reschedule your appointment

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.

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