Patient Screening Form

Patient Name

Date

1. Do you / they have fever or have you / they felt hot or feverish recently (14-21 days?)

Yes No

2. Are you / they having shortness of breath or other difficulties breathing?

Yes No

3. Do you /they have a cough?

Yes No

4. Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes No

5. Have you / they experienced recent loss of taste or smell?

Yes No

6. Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment

Yes No

7. Is your /their age over 60?

Yes No

8. Do you / they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Yes No

9. Have you / they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Yes No

10. Have you been vaccinated?

Not Vaccinated Partially Vaccinated Fully Vaccinated

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing, see the list of State and Territorial Health Department Websites for your specific area's information.

DENTAL TREATMENT CONSENT AND AFFIRMATION FORM COVID-19 REOPENING

I knowingly and willingly consent to dental treatment at Broadway Smiles by Dr. Vakharia and any designated associates or employees during the reopening phase of COVID-19.
I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms yet are still highly contagious. It is impossible to determine who has COVID-19 and who does not given the current limitations and availability in COVID19 viral testing
Risk of transmission: I understand that due to the frequency of visits of other dental patients under care, characteristics of the virus, and the characteristics of dental procedures, that I have risk of contracting the virus simply by being in a dental office, even though standard precautions are being observed.
I am unaware of being a possible carrier or infected: I confirm that I have not been tested positive for COVID-19 in the last 30 days and information provided in the ADA patient screening form (see page 1) is correct.
Contact with infected: I confirm that I have not knowingly been in close contact (defined as 6 feet or less) with someone who has tested positive for COVID-19 in the last 14 days, or with anyone that has had the symptoms stated in the ADA patient screening form (see page 1).
Public travel: I confirm that I have not traveled outside of the United States in the past 14 days. I confirm that I have not traveled domestically by commercial airline, bus, or train within the last 14 days.
Public Gatherings: I confirm that I have not been in a public gathering of more than 10 persons within the last 14 days.
INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the risks of contracting COVID-19 from the dental office and dental procedures. I reaffirm that I am not a carrier of COVID-19 nor infected with COVID-19 to the best of my knowledge. I voluntarily assume any and all medical/dental risks, including the substantial and significant risk of serious harm, if any, which may be associated with any phase of my treatment as a result of the COVID19 pandemic. I acknowledge that the nature and purpose of the dental procedures recommended under the current circumstances and restrictions have been explained to me and that I have been given the opportunity to ask questions OR decline the procedure.

I acknowledge that I have read and understand these statements.

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

Date

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Patient Screening Form

DENTAL TREATMENT CONSENT AND AFFIRMATION FORM COVID-19 REOPENING

BROADWAY SMILES DENTIST