More Smiles of Beverly Patient Advisory and Acknowledgment
Receiving Dental Treatment During the COVID-19 Pandemic
Please correct the errors described below.
You have presented to the office today because you have an urgent dental condition which 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 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 staff 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.
In order to reduce the risk of spreading COVID 19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
PLEASE ANSWER “YES” OR “NO” ALONG WITH YOUR INITIALS, TO THE FOLLOWING QUESTIONS:
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.